What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

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IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

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Saturday, July 23, 2011

Patient Modesty: Volume 43

Continuing on with the concerns of a former medical student as begun in Volume 42:

THE CONCERNS AND EXPERIENCE OF A FORMER MEDICAL STUDENT

July 11,2011

I was a [Moderator: school name deleted] medical student. Like many teenagers and young adults, I had never visited a gynecologist or proctologist. I did not come from a medical family either. And because pelvic and prostate exams are not mentioned in the premedical curriculum nor explained to medical school applicants and incoming [My Medical School] students, I did not know about these exams when I first moved to [Moderator: city name deleted] to begin my medical education.

My faculty did not bother to explain what bimanual exams were my entire first year of medical school. I only learned about them from classmates cracking jokes, and from receiving e-mails from students selling T-shirts that compared the exams to sexual activities, making light of the way we must complete the exam once on an actor as part of our Essentials in Clinical Medicine (ECM) course in our second year [Moderator: Link is in error and cannot be completed]. You can see from the link how insensitive and immature my classmates are to sell such T-shirts.

I immediately had problems with pelvic and rectal exams. I found them violating in concept. I believed it had to be wrong for my school not to explain to applicants beforehand that there was more to examining men than testicular exams and more to examining women than breast exams and catching babies. I thought that training students to lubricate and insert their fingers into male and female sexual organs was much more taboo than what many young students would creatively imagine on their own before matriculating. I thought it was not right to assume that every student must agree with digitally penetrative exams just because they are widely accepted as valid medical procedures, at least in this country. After describing these exams to my younger sister and a few friends from college, I was confident I was not the only human being who viewed these exams as more than just a little uncomfortable, but also violating.

There was ample support at my school for students with academic problems regarding written exams. But there was nobody to speak with for students who had personal, cultural, or ethical conflicts regarding clinical procedures. I did speak with a school psychologist who specialized in stress management because she gave students her contact information during orientation week, but all she did was invalidate my perspective by repeating "There is nothing sexual or violating about these exams." Realizing that a broken-record psychologist could not alleviate my stress, I decided to complete the first year curriculum and resolve my issues directly with faculty over the summertime.

I started reading Dr. Bernstein's Blog as a medical student, and contacted him back when I was trying to resolve my concerns with faculty. He bought to my awareness today that the essay I wrote for the Blog does not mention my personal career aspirations, which is something I told him about last summer. I realize this is a pertinent detail that several readers have asked about in their responses.

I entered the program at my school to prepare for a career in translational services between medicine and investigational science. I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology.

When I learned about these invasive genital exams, I found them violating enough to refuse when unnecessary. Realizing they were not part of my future responsibilities, I thought the most professional and honest approach would be to discuss all of this with faculty

Over the summer, I confided in faculty that even though I understood many people saw these exams as being just another part of the physical exam, I saw pelvic and rectal exams as being violating procedures, and that unless I went through some psychological change where I could perform them without feeling violated, I would decline to perform them, especially in non-emergency scenarios such as practicing on an actor in an artificial environment, and especially since it was not listed as a graduation competency to students beforehand (or even at all anywhere). What happened when I said this is they withdrew my scholarship, and shunned me for asking for "special privileges". I withstood so much abuse when I brought the topic up with faculty, ridiculing me with "What? We have to tell students that doctors touch people?", guilt-tripping me with "If you cared about patients, you would do the exam", and victim-blaming me with "You knew all about these exams before you got here, you just repressed it."

********************

Over the summer, the first person I contacted was the head instructor of ECM (the physical exam class where we must complete these exams). I vaguely told him I had "concerns" about the ECM course for second-year students. He offered to meet with me, but said most students speak with other instructors of the course first, and then with him if things are not resolved. So I spoke with all the other course instructors, and by then he knew what my issues were, and was no longer interested in meeting with me. I did learn a lot of unacceptable facts about the ECM class from the other course instructors though.

I was appalled and frustrated to realize my school has watched students suffer personal conflicts like me for decades:

1) Every single year, the instructors watch a "few" students resist these exams. One instructor told me these students say "I just can't do this" and "I don't want to do this". Some students abruptly walk out of the exam room, and some postpone their dates, all the way until summertime when they must complete it once to advance to third year.

2) Students have fainted during the exams.

3) Students have cried during the exams. The worst was a recent student who said she was a rape-survivor and had problems with the male rectal exam. My instructors still forced her to do it, and she left the room sobbing in front of the actor and instructors.

4) The instructors have a rule that one female must be in the room for the male rectal exam. The rule was established to mitigate any "homophobia" among male students, and apparently my school thinks the presence of a female neutralizes any viewpoints students might possess that the exam is a "gay thing". I thought this "rule" reeked with discrimination and hypocrisy. It seemed to me this "rule" was conjured up decades ago by the primarily male heterosexual faculty who empathized with problems male heterosexual students as a selective group would face, and made it easier for them to at least graduate, when many male students never even asked for it. The most disturbing part about this "rule" though is that the faculty EXPECT a few young students to be unable to desexualize the prostate exam when it is introduced to them. To then force students to complete the exam, knowing that some cannot desexualize it, must be sexual abuse. But not wanting to "scare students away", these instructors deliberately keep students in the dark until they have invested too much time and money into school. Because at that point, students who find these exams unacceptable must choose between getting sexually abused or crawling away with a mountain of debt as a medical school dropout. The instructor who told me about this "rule" said it was handed down to her when she took the position in 1982. In other words, this "rule" is over three decades old!

What do you think of these four points? I think they unfold like rape scenes. A self-proclaimed rape-survivor leaving the exam room sobbing? Students crying and fainting while doing "intimate exams" that were not explicitly explained beforehand? Students "resisting" and "postponing" the exams for months? One instructor assured me that I was not out of place, and said he always sees students "make horrified faces". Unfortunately, his comments did not make me feel better, they made me feel angry that my school failed to question why this is the case. It disgusted me that nobody advocated for the rape-survivor. I believe they raped a rape-survivor. And it outraged me that this student cried in front of her peers, and then felt she needed to reveal personal information about herself too. There is no justification for the fact that they did absolutely nothing after that for future students.

I was sickened by the degree instructors deny they are hurting a few students each year. They assured me "I always ask those kids who keep postponing the exam how it turned out, and they say it was not as bad as they thought." What else can these students say when their own abusers fish for an agreeable response like that? The instructors even told me matter-of-factly "Students faint during the pelvic exam because they did not eat a big breakfast." They cannot possibly be keeping tabs on 200 students breakfast schedules. It irritated me they never considered why nobody fainted during the ear exam. As of now, their "solution" to the fainting episodes is to remind students earlier in the week when they explain the pelvic exam workshop to eat a big breakfast on the morning of the workshop.

********************

I read a book "Public Privates" by Terri Kapsalis. When I learned halfway through the book the author was a pelvic exam actor at [My Medical School], I was shocked to discover she wrote an entire chapter about [My Medical School] students having problems with pelvic exams. This book was published 20 years ago, and nothing at my school has changed. Here are some quotes from her book about my school:

1) [The author discusses a paper by a physician named Buchwald] "Students seem to find it very difficult to consider female genital display and manipulation in the medical context as entirely separate from sexual acts and their accompanying fears. Buchwald's lists of fears makes explicit the perceived connection between a pelvic examination and a sexual act. "A fear of the inability to recognize pathology" also reflects a fear of contracting a sexually transmitted disease, an actual worry expressed by some of Buchwald's student doctors. Likewise, "a fear of sexual arousal" makes explicit the connection between the pelvic exam and various sexual acts. Buchwald notes that both men and women are subject to this fear of sexual arousal. "A fear of being judged inept" signals a kind of "performance anxiety," a feeling common in both inexperienced and experienced clinical and sexual performers. "A fear of disturbance of the doctor-patient relationship" recognized the existence of a type of "incest taboo" within the pelvic exam scenario."

... "Buchwald's work deviates from most publications dealing with the topic of medical students and pelvic exams. Largely, any acknowledgment of the precarious relationship between pelvic exams and sex acts is relatively private and informal, taking place in conversations between students, residents, and doctors, sometimes leaking into private patient interactions. For example, as a student in the 1960s, a male physician was told by the male OB/GYN resident in charge, 'During your first 70 pelvic exams, the only anatomy you'll feel is your own." Cultural attitudes about women and their bodies are not checked at the hospital door."

... "In his article about medical students' six fears of pelvic exams, Buchwald accepted student fear without either questioning why young physicians-to-be would have such fears or searching for the cultural attitudes underlying them."

2) [The author discusses that schools hired prostitutes to teach the exam] "In a sense, the patriarchal medical establishment took the position of a rich uncle, paying for his nephew, the medical student, to have his first sexual experience with a prostitute. This gendered suggestion assumes that female medical students are structurally positioned as masculinized "nephew" subjects as well."

3) [The author quotes a fellow pelvic exam actor] "I think the students are afraid it's sexual. They're afraid about how they're going to react, whether they're going to be aroused, but it's so clinical."

4) "Only with the use of GTAs [pelvic exam actors] have medical schools attempted to incorporate women patients' thoughts, feelings, and ideas into pelvic exam teaching. And yet, as these feminist teachers pointed out decades ago and as my experiences have occasionally confirmed, it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality."

The author of this book is correct: There is no validation from faculty at [My Medical School] that some students suffer problems regarding these exams, and there is no effort to investigate why this is the case. I also agree there is no search for "cultural attitudes" that could underlie students perceiving these exams differently. In fact, although I have American citizenship, I was raised overseas from age four and returned to America for college at age nineteen. I retrospectively learned that in many developed nations, the thought of asymptomatic women paying strangers in white-coats to routinely penetrate their vaginas is the exception rather than the norm. In Korea, for instance, some women use vaginal swabs in the privacy of their homes. In Japan, screening for cervical cancer at all is not commonplace. In other developed countries, there are self-pap tests that some women use because they find the traditional gynecological exam to be inappropriate in the absence of symptoms. In addition, the developers of the CSA blood test cite "cultural taboos" as being a primary motivation for them inventing a non-invasive alternative to check for cervical cancer. So I think my school is very ethnocentric to believe all incoming students automatically agree not only with these exams, but also with practicing them on asymptomatic actors. It is undeniable some students discover personal clashes that might derive from cultural upbringings while learning about the most taboo aspects of physical exam for both sexes, and I find it unethical that schools would not inform students about these potential problems before they move to new cities and matriculate.

At the same time, the author conveys similar beliefs as the instructors I met at [My Medical School], hastily diagnosing students as having "anxieties" and "fears" that they can "cure" us of via "education". I think the quote the author provided from a fellow pelvic exam instructor ("Students are afraid it's sexual") is nauseatingly narrow-minded. How does this woman believe she can tell all adults that an exam, mechanically the same as digital sex, is not sexual? Why does she think she can speak her mind for all adults about human sexuality in medicine by resorting to empty buzzwords like "professional" and "clinical" to do so? In fact, she cannot define what is and is not sexual (or sexually violating) for any other adult.

This reminds me of one instructor who concluded I had an "irrational phobia". Do you think it was fair for this instructor to tell me I had a "phobia" of being forced to have digital sex with an actor without my consent? Because you could easily make the reverse argument: Students who do not want to do these exams when introduced to them (as this apparently happens each year), but still complete them have "phobias" about disobeying orders from faculty, or have "phobias" about standing up for themselves, or have "phobias" about what instructors will think of them if they admit they see a medical exam as being sexual. The same with patients too: I have seen peer-reviewed papers written by gynecologists investigating why some women have "fears" about getting exams. But the counterargument here is that women who dread the thought of being humiliated and penetrated by strangers, but force themselves to suck it up, have hypochondriac "fears" about developing a rare cancer and benefiting from a notoriously inaccurate exam. Depending on their lifestyles, some women are more likely to be harmed than benefited from the outdated pap smear, and the World Health Organization does not recommend ovarian cancer screening via bimanual exams. For these reasons, I believe smart and responsible women can decide to never submit to these exams while asymptomatic, without being diagnosed by pushy and one-sided doctors as having "curable fears".

It is too easy for instructors to label and ostracize students as having "fears". These instructors told a rape-survivor she was being irrational to "fear" the prostate exam. What is particularly evil is they knew this teenage girl or young woman likely did not know about taboo old men healthcare to decide for herself before starting school whether or not she found completing a prostate exam to be acceptable. In any case, her "fear" turned out to be a rational one because the experience did cause pain, as she expected, seeing that she left the room crying. These instructors pride themselves on walking over students and their problems, and believe that with their supremely rational minds, they can triumph over anything, when in fact they have not proven any strength unless they have all been raped themselves. So who are they to judge a rape-survivor student with long-term effects of depression? And then to boast that they gave this student such a valuable educational experience, just because they cannot relate to her suffering from traumatic life events? I thought that was just plain childish.

I do not think my instructors are very intelligent. There is more to intelligence than exercising the rational mind. The author refers to these exams as being a "first sexual experience" for many students. If it is indeed true (that medical exams can be sexual experiences), then forcing teenagers and young adults to perform them without consent using shame and blackmail, when it causes problems for a few of them each year, is institutionally-sanctioned serial sexual abuse and rape. At least that is how my intellect - both rational and emotional - sees it.

************************

After I spoke with all physical exam instructors, they sent me to the "Associate Dean for Curriculum", who is also an OBGYN. I met with him twice, and our second conversation bothered me.

He told me he was "ignorant" medical students had problems. But really, he was anything but "ignorant" since he works with the same instructors who watch students cry and faint.

I also brought one article about teenagers and women getting unwanted pregnancies because they could not obtain birth control from gynecologists when they refused pelvic exams. I brought this last article because I empathized and related to the female patients, as I would also refuse the exam if I were in their positions. The article was pointing out that because the medical community does not respect and accommodate these women and their opposition to pelvic exams, it leads to bigger problems like unwanted pregnancies. And I felt that was a similar message to what I was trying to voice to my school: I think a small number of medical students can find out they disagree with exams, and they should no longer be marginalized and ignored for it because that only leads to bigger problems.

When I handed him the paper, his demeanor changed from the previous meeting, and he suddenly raised his voice at me (even though I never raised my voice at him). He actually balled up his fist like he was holding pills and growled at me "If I have something a patient needs, I withhold it until they get the exam!" He was steaming with anger, even though I never thought to question his practice at all. I had read about why it was unethical to require pelvic exams for birth control (http://www.law.harvard.edu/students/orgs/jlg/vol27/dixon.php), but I assumed the doctors who abused their power in this manner were working in private clinics out in the boonies. It never even crossed my mind that an OBYGN Dean of a medical school would fit that profile.

Shocked and creeped out, because I saw his true color, I asked "Shouldn't doctors at least tell patients they could go elsewhere and get birth control without a pelvic exam?" I thought it would be lacking informed consent not to do so. He just sneered at my comment. It was very clear to me this person went into gynecology for all the wrong reasons one might expect. It infuriated me he could not even pretend to empathize with the girls and women in the article who found pelvic exams to be intolerable, just as he could not empathize with his own students who have felt the same way for years. Any gynecologist, especially one who is training the next generation of gynecologists, should understand and respect how various patients feel about their reproductive rights and healthcare. Hurdles should never be imposed for women seeking contraception. In my opinion, this has nothing to do with health care, and everything to do with power, control, and making money.

His thinking and practice is outrageously sexist: When he was a teenager who needed a condom, he did not need to confront an old woman in a white coat who withheld what he needed until he had digital sex with her first. He presents himself as someone who cares so much for women, but then dupes them into accepting pelvic exams for birth control, even though the World Health Organization and numerous medical associations have consistently stated that the only recommendation is a blood pressure check, since hormonal contraceptives are as hazardous as Aspirin. Medically speaking, there is no greater logic to requiring pelvic exams for women who want birth control than there would be for requiring prostate exams for men who want Viagra.

You can only imagine some terrible scenarios he has exploited: An adolescent patient from a poor family shows up for birth control but does not want a pelvic exam, and does not know beforehand that she will be pressured to accept one. Once in the office, she might view doctors as authoritative figures whom she cannot question. She might be time-pressured for immediate access to birth control. She might be too scared to challenge a doctor. She might find it more embarrassing to try to resist the exam. She might be fooled that the pill will harm her body if she does not accept the exam. She might be intimidated by the medical setting, and maybe cannot speak fluent English. At that point, she can either run away from the exam room (and get undesirably pregnant), or reluctantly submit to the exam (and suffer rape-like symptoms). And I am not just speculating here, I have read about female patients who realize they were mistreated after being coerced into something they adamantly did not want but ultimately accepted because of false guidelines presented to them. I have also read about women feeling "raped" from this practice, and driving for miles to find a doctor who actually follows the law.

I wonder why no students speak up when they see him mistreat patients? Maybe their voices have no impact. Maybe they worry they are out of line to defend patients. It agitates me because I know his misogynistic attitudes have an exponentially poisonous impact, seeing that his peers actually respect his philosophies enough to bestow him the responsibility of training future gynecologists at the largest public medical school in the country.

When I was about to leave the room, I recalled a discussion I had with a kind-hearted classmate who recently drove me home. I told him I had problems with these exams, and he urged me to speak with faculty and resolve the issue. Then he told me although he did not have problems performing the exams, he did have problems the way some instructors handled them: He said he shadowed the head ECM instructor, and watched him reprimand each female patient who asked for a female to do her pelvic exam. Evidently, the instructor believes such requests are backwards and bigoted.

So when the "Associate Dean for Curriculum" asked me if I had anything else to add, I said I was concerned about the head ECM instructor teaching students to reprimand patients when they prefer one sex over another for intimate care. The Dean scolded me, and said he applauded the instructor. He believed it was sexist for me to assist these patients and their wishes. He asked me "Would you ask a black person to leave the room? Would you ask a Jewish person to leave the room? Would you ask a short person to leave the room? Probably. Because you would ask a man to leave the room!"

I thought his analogy here was meager and self-serving. Funny how he was offended by modesty in medicine to vilify it as condoning sexism, when he is the one who abuses his position of power to do such despicably sexist things as withholding birth control from girls and women who refuse pelvic exams.

Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgements on their patients and their sexual values and identities.

Some patients might find it more logical to speak with a provider who has experienced physical problems, like a female patient talking about cramps. And some patients might prefer same or opposite intimate care to protect the intimacy between their partners and spouses. How can a health provider admonish a patient and his or her relationship values?

In all honesty, I do not believe that a woman asking for another woman to do her pelvic exam is sexist. Many women perceive the act of getting naked and spreading into the lithotomy position as being sexually vulnerable and submissive. Even if a woman consciously believes that male and female doctors are equivalent caregivers, her natural instincts might strongly prefer a female examiner because she could not get impregnated by a strange female, as opposed to a strange male, between her naked legs strapped in stirrups. The consistent prevalence then of females requesting female intimate caregivers must have instinctive and deeply emotional roots, and must be accommodated by doctors without judgement or ridicule. Because when these women are demonized for making reasonable requests, doctors are punishing them for protecting themselves at a primitive and instinctual level. Hence, these doctors are docking points off patients for being human, known as dehumanization.

I have to say I find it troubling that these male providers harasses female patients for requesting same-sex care. The power differential is too unfair. Most (American) female patients are very young when they have their first pelvic exams and are too often pressured by biased propaganda and brainwashed mothers to get them without the opportunity to judge for themselves whether it is really necessary or whether they are candidates for less invasive alternatives routinely offered in other developed countries. The pelvic exam is also longer in duration and so much more visually exposing than the prostate exam. Women also face additional hurdles since our society is still a very patriarchal one, where women are sexually abused by men at much higher rates than any other combination of sexes. Even if a woman has not been directly sexually abused, she has certainly been emotionally abused from a very young age, knowing female friends who have been sexually abused (often by men), reading newspaper articles about women being raped (often by men), reading history books about villages of women being raped (often by men), receiving catcalls and verbal sexual abuses (often by men), and knowing about pornography and prostitution and late night clubs where women are sexually belittled (often by men). She has been surrounded with evidence her whole life that some men might view sexual parts of female bodies differently. Unfortunately, OBGYN is not much different than these phenomena anyway, as it is a field that has abused the sexual organs of women for decades and was created primarily by male minds. And so when a female patient requests same-sex care, it may be because she has read books such as "Women and Doctors" by John M. Smith, MD, which revealed frightening statistics such as how much more likely it is for male gynecologists to recommended unnecessary hysterectomies, and how much more prevalent it is for male gynecologists to be reported as sexually abusive.

So how can this Dean, who holds birth control hostage from girls and women until they submit to stirrups, relate to patients who ask for modesty accommodations anyway? Any physician or nurse, male or female, should be open-minded and accommodating with all patients and their valid and legal requests for same or opposite intimate health care, as well as their legal right to refuse degrading exams for contraception. Unfortunately, instead of accepting his patients as human beings with modesty concerns, he exploits their situations to elevate his own status as the heroic physician who is educating students to end what he conveniently believes to be sexual discrimination in medicine.

Even if these instructors are so black-and-white in their thinking to believe they are being discriminated against, they still hold responsibility to follow the law and teach students to do so as well. If they dislike the law, they can always orchestrate their own rallies to advocate for fewer patient rights. But I wonder how honest and humanistic they would feel about their pursuits. All they would be doing is transferring the alleged target of discrimination to the group of people who are in the much more vulnerable position, the patients.

************************

The OBGYN "Associate Dean for Curriculum" said he did not support my conflicts with the curriculum, and sent me to the "Senior Associate Dean for Educational Affairs". This Dean gave me an unhelpful psychotherapeutic session the moment I walked into his room. Before I could explain in my own words what I came to speak about, he asked me "Do you remember anything happening to you that would make you see an ear exam differently than a pelvic exam?"

I thought it was unprofessional for him to ask me personal details about my life, but I told him I have never been sexually abused. I told him some students might find the exam itself to be violating if they are not told about it beforehand. He shook his head like I was a child trying to convince him Santa Claus was real, and told me the only explanation for a person to feel angry over medical exams was if he or she had been abused. Even when I reiterated this was not my case, he told me to seek help from a psychiatrist and "connect the dots" to my abusive upbringing. He went so far to ask if I had siblings, and suggested they also seek help.

I did not think this Dean seemed like an intelligent person to preach about sexual abuse inside or outside of medicine, seeing that he gave no exemption to the student who did admit to an abusive past, and maybe even believed the prostate exam granted her the ability to stop overreacting to whatever caused her to cry.

When searching for criticism of modern gynecology, I came across a popular book "(Male)Practice" by Dr. Robert Mendehlson, who was a pediatrician at [My Medical School]. The author stated:

"I will never forget a student of mine who wanted to specialize in obstetrics but couldn't swallow all of the ridiculous obstetrical intervention that he was being taught. He began to ask questions of the obstetricians: Why were the mothers' feet up in stirrups? Why were they giving the women analgesia and anesthesia? Why were they inducing labor at such an early stage? Why were they performing Caesarean sections when there was no clear indication of need? Did he get answers? No, but he got action. He was referred by the chairman of the department for a psychiatric examination, because any student who asks a hostile question in medical school is presumed to be 'disturbed.'"

This book was written in 1982, and still thirty years later at the same school, when students disagree with sensitive medical procedures, the Deans immediately send them in for psychological evaluation. I whole-heartedly concur with the author: Instructors at [My Medical School] stubbornly maintain there is something wrong with individual students each year, and never with the system itself.

Even worse, this Dean promotes a philosophy to his students that as long as nudity, touching, and penetration occur in the medical setting, then no sane person could possibly feel violated. This is far from the truth, and patients are beginning to speak up about their rights to refuse, request accommodations, and seek alternatives for "intimate" procedures.

For instance, I read the term "birth rape" has been coined. While I understand the term may be legally problematic, I find it conceivable that some women can only describe it this way after what was done to their bodies without permission. And I do not think these women are upset having life-saving C-sections, instead of natural dreamy births. They are upset having unnecessary and aggressive interventions without consent. Can it really be true that so many women must have their labor induced (a known risk factor for pelvic floor damage, perineal tears, epidurals, and C-sections)? Do so many women need episiotomies, when there is no evidence that artificial tears are safer than natural tears, which are rare anyway? Large studies of home births with trained birth attendants show that the majority of women can give birth without interventions, with less injury to mothers and babies, and no increased risk of mortality to either.

There is an unfair rule from doctors that all women automatically accept fingers and instruments in their vaginas if they wish to deliver a baby, even when births are proceeding smoothly. Doctors have an obsession with "checking progress" and recording numbers, with no respect for women who feel the procedures are barbaric. Some insurance providers cash in $250 per bimanual exam, which generates big bucks when doctors perform multiple "cervical checks". There are less demeaning maneuvers that cause less vaginal infections, but these alternatives are never offered. Instead, women who decline pelvic exams and episiotomies receive them against their wills! The baby needs an emotionally healthy mother, and that does not happen when she leaves the experience with so much trauma to call it "birth rape".

As for cancer screening, women are kept in the dark about less intrusive methods to test for cervical cancer (CSA blood tests, urine tests, vaginal swabs, and self-pap tests). Unlike this Dean, I strongly believe patients could feel mistreated by undergoing traditional pap smears should they discover that alternatives, which could have preserved their dignities, were not fairly discussed with them, or should they discover they were not even candidates for cervical testing in the first place.

A report released by Dr. Angela Raffles (cervical cancer screening expert from the UK) demystifies pap smear risks - 1000 women need to be annually tested for 35 years to save one woman from cervical cancer. Meanwhile, 95% of them (950) will require one or more biopsies that can be harmful (emotional stress, sexual problems, cervical stenosis, pregnancy complications, and even infertility). Another article by pathologist Dr. Richard DeMay "Should we abandon pap smear testing?" exposes the fact that cervical cancer mortality was trending downward before the application of pap smear testing, and that when malpractice suits led to higher false-positive rates (and hence more biopsies) cervical cancer mortality actually increased. Hence, the widely proclaimed association between the introduction of the pap smear and decline of cervical cancer might be more casual than causal.

Most doctors do not tell women that "the best kept secret of cervical cancer prevention" is through practicing safe sex and avoiding smoking, not through pap smears. Some women have microscopically slim chances of benefiting from the pap smear, such as virgins, women who only have sex with women, and long-term monogamous women. The same is true with ovarian cancer screening via pelvic exams: The American Cancer Society recommends against it. Why should doctors keep sticking their fingers in places they do not belong when there are no proven benefits?

It is clear to me that dishonesty surrounds much of these "preventative" gynecological exams. Doctors established these tests (money or fear of being sued), and the individual was disregarded. It became: Every Woman must have these exams with No Alternatives.

I can say with confidence that medical students are trained to think this way. In fact, in our first year of medical school, all students practiced interviewing patients with a standardized list of important questions. We asked ALL women: "When was your last pap smear?". But we asked NO men: "When was your last prostate exam?" It would almost make more sense to assume all older men are candidates for prostate exams, than to assume all women are candidates for pap smears since cervical cancer is an STD and so some women are not eligible. Also, the incidence and death rates of prostate cancer are much higher than those of cervical cancer, so it must not be about the numbers. In addition, cervical screening can be a more vulnerable process than prostate screening, because men often have the option of the PSA test (while the CSA test is never offered to women). So really, our first lesson was that female patients do not mind being humiliated in the medical setting, and that we should assume all women accept traditional gynecological exams, even the ones who could only be harmed by them in the first place!

The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education.

I believe most of this ignorance stems from the way doctors are trained. When medical students learn to take sexual histories, we are trained to ask: "Do you have sex with men, women, or both?" (As a side note, I always thought the question should also include "or none" to represent all patients). Before the gay rights movement, this question was systematically swept under the rug to favor the heterosexual population, and hence made gay and bisexual patients less comfortable to openly discuss their sexual histories. Doctors now know not to assume all patients only have straight sex, and this is something that was strongly enforced at my school. I cannot imagine any of my classmates forgetting this simple question, because we are trained and repetitively graded to ask it verbatim from the very beginning. I think many medical students would feel confident to question one of their superiors if they did notice he or she was discriminating against sexual minorities this way, since it is a highly-valued aspect of our training.

On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well.

Unfortunately, medical students know they will be shunned if they advocate for patients this way, since sex preference for intimate exams is not an official part of the curriculum. Not only that, but as I mentioned earlier, the instructors at my school reprimand students who bring the topic up for discussion. Therefore, I think dishonesty and silence are fostered in medical school, because I suspect some medical students make their own requests when they are in the vulnerable position as patients. And so they must empathize with patients, but at the same time they must sell their integrity by not questioning their superiors and fitting into what is expected of them, which is to work toward becoming competent physicians who possess minds too perfectly rational to see anything sexual about the exams, and hence too rational to understand why patients might seek modesty accommodations. In other words, doctors pretend not to "see an ear exam differently than a pelvic exam" since they fear admitting so would be a transgression of their medical conduct, and unfortunately this means distancing themselves from patients who do have modesty concerns about exams due to their sexual nature.

I think many medical students sacrifice their integrity subtly at first, and then succumb to the Domino Effect. At first, maybe a student knows he cannot desexualize the pelvic exam, but fearing how his instructors will react, he says nothing, and performs it poorly at the expense of the patient. Next, he might watch an instructor reprimand a female patient when she admits she is not comfortable surrounded by male medical students for her pelvic exam, and he does not stand up for her even though he believes she should not be reprimanded for her request. Now that he has grown more desensitized and dependent on fitting into what instructors expect of him, he might watch an instructor misinform a patient (out of conflict of interest) that pelvic exams are always necessary to obtain birth control, and even though the patient seems weary about the procedure, he does not question the ethics of his instructor. After all, he cannot express his concerns without implying that the instructor is sexually abusing his patient, which would certainly label him as a whistle-blower.

After that, an instructor tells the student that if he admits he is a medical student, then no patients will not allow him to practice sensitive exams on them, and so he follows the advice to flat-out lie to patients about already being a doctor. Ultimately, he agrees to practice pelvic exams on anesthetized patients who have not consented to it, because his instructor tells him these women would have adamantly refused students using their bodies for didactic purposes, and so it is a great opportunity for them to practice their exam skills on unconscious bodies that cannot protect themselves. The student believes the most important skill with a pelvic exam is to obtain informed consent. He sees this "educational" setup as being no different than gang rape. But he has already jeopardized his ethics so many times in the past in relation to sensitive exams. So he does what apparently many medical students do in this country, and gang rapes his own patients: (http://www.theunnecesarean.com/blog/2010/8/30/medical-student-wont-perform-pelvic-exams-on-anesthetized-pa.html).

Gang raping anesthetized patients is apparently a "time-honored tradition" in medical schools, an ethical problem that has garnered media attention for decades, but has never provoked enough frenzy to encourage change. I never witnessed this practice as a first-year student, but I bet my life it is something I would have encountered had I graduated from [My Medical School]. I strongly suspect this because when I was sent to the OBGYN "Associate Dean for Curriculum", he cautioned that I would face additional dilemmas if I refused to perform pelvic and rectal exams during clinical rotations, and said "You might also have a hard time with... Never mind, we do consent all our patients here." It was patronizing he thought I was gullible enough to believe in his statement when he had to "correct" himself. In any case, I already knew this person was not sincere because he had already lied to me earlier in the conversation. (One of the news articles I brought was about Muslim male medical students refusing certain exams on female patients. When I handed it to him, he casually commented "Oh yes, I have read about this before," when the very reason I brought him articles was because he had told me in our first meeting he was "ignorant" students had problems with aspects of physical exam).

The way he corrected himself mid-sentence told me that in fact [My Medical School] has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools. This is a topic that was never officially discussed at my school, and I only learned about it through my own research. Hence, students at my school are not prepared to challenge medical gang rape because they will be branded as trouble-makers for suggesting their instructors are gang rapists. This is why I believe most medical students trade in their ethical tenets to complete school, because otherwise repulsively unethical practices like gang raping patients would have died long ago had students followed their hearts, refused to participate, and reported their instructors for legal action.

Two other quotes from Dr. Robert Mendehlson, the pediatrician at [My Medical School]:

"The tragedy of this dogmatic approach to medical education is not only that it screens out the most thoughtful, intelligent, and ethical students, or that is perpetrates traditional idiocies, but also that it virtually forestalls the application of creative noninterventionist approaches to medical practice. Dr. Roger J. Williams put it well in his book, Nutrition Against Disease: Medical schools in this country are standardized (if not homogenized). A strong orthodoxy has developed that has without a doubt put a damper on the generation of challenging ideas. Since we all have one kind of medicine now - established medicine - all medical schools teach essentially the same things. The curricula are so full of supposedly necessary things that there is too little time or inclination to explore new approaches. It then becomes easy to drift into the convention that what is accepted is really and unalterably true. When science become orthodoxy, it ceases to be science. It ceases to search for the truth. It also becomes liable to error."

"My colleagues who head the nation's medical schools boast that this process of "survival of the fittest" assures Americans of the finest medical care in the world. My observation is that doctors are taught to provide a lot of medical and surgical intervention, but I don't see evidence of very much 'care.' The fittest do survive, but what are they fit for? They are the survivors of a heartless system that too often weeds out the best and the bravest - the students with compassion, integrity, intelligence, creativity, and the courage to resist the destruction of their own moral and ethical codes."

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When they withdrew my scholarship, faculty told me they "firmly believed" future doctors must competently perform these exams. But this obviously is not the case at all, otherwise they would not graduate students who did not complete the exams objectively. All the students who cry and faint and make horrified faces certainly are not demonstrating objective behavior. Moreover, the school does not even give all students the opportunity to prove they have desexualized any type of medical exam, since they enforce their "rule" that one female must be present during the male rectal exam. When problems like this are marginalized, it inevitably translates to a small number of students advancing to clinical rotations ready to hurt patients expecting adequate exams, since these students feel too much pressure to act competent as future doctors, they cannot admit the exam is something they never desexualized (and they cannot admit they might faint or cry on a real patient, like they did on the actors). Students like this avoid pelvic exams as much as possible, and write "pelvic deferred" in patient charts, because they cannot be honest enough about their shortcomings to ask another provider who feels more comfortable to perform the exams instead (Article: "Managing Emotions in Medical School").

So by trivializing something important, like the inevitable cultural and personal attitudes and barriers about human sexuality in medicine, my school is hurting patients by exposing them to students who are too busy hiding their inadequacies. I thought I was more professional than these students to admit I had visceral problems over these exams, than to not admit so and make an already unpleasant exam even more unpleasant for patients. It is blatant that the only thing faculty "firmly believed" was that students never stand up for themselves if they cannot find peace with a small component of the curriculum.

Before I left, I recommended to several faculty members to start screening students. It is unprofessional and unethical to not explain these taboo exams to students before matriculation. When I suggested this to the OBGYN "Associate Dean for Curriculum", he nonchalantly replied that they "might consider it." He said this in a very condescending and indifferent tone of voice, even though as a physician, he should respect and practice full informed consent. The only person who ever got back to me was one of the ECM instructors who sent me an e-mail saying she would voice my concerns for future students but she "can't promise that there will be a change."

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I am not angry I did not graduate from medical school: I do not want to work in such a hostile and uninspiring environment. But I am angry I moved to a new city to start school without knowing that the same problems that mistreated students in the past would mistreat me because my school will not clean up their system. I am angry I had to arrange so many embarrassing conversations with faculty, only to be told I was "too immature", "too sheltered", "too squeamish", and sexually abused as a child. I am angry my school ostracizes a minority of students each year over something personal like their sexualities, and believes they should all have to change their views to assimilate to those of the majority. That is something that has always bothered me.

I hope Dr. Sherman and Dr. Bernstein continue to raise awareness for patients to know and exercise their options and legal rights regarding sensitive medical exams. And as a woman, I hope American girls and women start to explore alternative practices and philosophies about their bodies and reproductive healthcare outside of the rigid setup traditional modern gynecology has to offer. I could never accept non-emergency care from OBGYNs now that I know how they are trained. If I ever wish to have a baby, I will not think twice about home-birthing with midwives because I do not want to be a woman who receives demeaning and dangerous interventions when unnecessary and often harmful to both her and her baby. And I am ecstatic to see that American women are becoming more informed about their birthing options, thanks to documentaries like "The Business of Being Born" by Ricki Lake.

Much of what I wrote here ties into various medical modesty and ethical concerns discussed on Dr. Bernstein's Blog. That is why I agreed to publicize all of it here on his Blog. I also do not mind publicizing this story further anywhere else if it might prompt a change in some of the problems I detailed.

I wanted to end by saying that I believe there should be a requirement at the national level that students are explicitly told about these exams when they apply to medical schools, which should not be laborious to implement because students all use the same application website. I contacted several individuals last fall, told them my story, provided them with news articles about students fainting and crying, and none of them took me seriously. Some of the people I contacted included the "Senior Director of Student Affairs and Student Programs at AAMC" and the "LCME Assistant Secretary". These people told me they thought most students knew about these exams beforehand. First, I have never believed that "most" is ever enough; it does not validate the fact that the system currently tramples over a minority of young students. Second, I do not know where they got their flimsy statistic that "most" know about these exams anyway, since most students have never visited the proctologist, and at least half have never visited the gynecologist. These people also told me different students face different "challenges", and so they cannot cater to one "challenge" over another. I do not believe these intimate exams are "challenges". I believe any exam that could be construed as sexual (and sexually violating) must be fully explained and consented. Otherwise, it could be serial sexual abuse and rape.

I also want to report the OBGYN "Associate Dean for Curriculum" for not following the law that women can get birth control without pelvic exams, as well as report both him and the head ECM instructor for not properly educating students about the BFOQ patient modesty law. These individuals are teaching and encouraging hundreds of future physicians each year how to be insensitive about sensitive exams, and I want to do something about that. The problem is I do not know how to report these authoritative figures, unless there are freelance lawyers any readers out there might know about who advocate for patient rights.

I look forward to reading any comments and suggestions from readers.

NOTICE: AS OF TODAY AUGUST 27, 2011 "PATIENT MODESTY: VOLUME 43" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 44

138 Comments:

1. To commenters suggesting these exams are necessary to be a ‘well-balanced physician’, I disagree. Many medical schools do not even require their students to learn how to take blood. This is a basic procedure, which I feel many doctors (with the exception of OBGYNs) will perform more often than a pelvic exam.

2. I wonder if the student had a similar reaction to different type of exam (say an ear exam) and refused to perform it, if she would have had the same reaction. I am guessing they would have been more accommodating.

3. The student explicitly mentioned she did not grow up in the US. To say she was ‘childish’ or ‘immature’ for not knowing about these exams is unfair. Other countries do not stress these exams for asymptomatic patients. So there is a great likelihood that many of the international students also do not know about these exams prior to entering medical school.

4. For any curriculum in any educational field I have been in, I have been given the requirements to graduate. As an undergrad, it specifically listed out what I needed to graduate (how many language classes etc). Same for graduate school. These were laid out clear to me before I joined. I do not see why medical schools should be exempt from being clear on requirements

In addition, the material the student brought into light about performing exams on anesthetized patients is frightening. However, what scares me just as much is that the director of the OBGYN is instructing his students to mistreat their patients, belittle them, and break the law. Is there no legal recourse for this?

Also, I wonder what the blog moderators (dr sherman, dr maurice, and doug) think of the story? Does stressed student’s reaction to learning about these exams surprise you? And do you agree with the decision made by the school?

Thanks for your comments, Erica. I'll sum up my reactions and thoughts. 1. I have mixed feeling about whether medical students should have to at least learn these exams. I see arguments on both sides. At the same time, I don't think just learning to do these exams necessarily makes a person a better or more complete physician. I don't see why there can't be medical degrees that don't require this kind of training, but strictly specify the kind of work certain doctors can and cannot do. 2. I'm not surprised at the lack of respect, hostility and bullying demonstrated toward medical students within the cultures of some medical schools. That's nothing new. I hope it's changing but I won't hold my breath. To believe that this kind of culture doesn't transfer eventually down to the patient, is naive. 3. The issue of performing exams on anesthetized patients without their specific consent is nothing new in medicine. Look at the consent forms patients sign when they enter the hospital. Look at the fine print. If you're not careful, you're agreeing to all kinds of things you may not be consciously aware of. 4. Much of this is about the culture of secrecy in medicine. How much do you tell the patient? How do you get the job done without frightening or stressing the patient? What they don't know won't hurt them. They're better off not knowing, for example, all that goes on in the OR. And for some patients, that's the way they want it. Not so for others. But it's just easier to treat everyone the same. 4. The conflict within medicine about access to bodies is part of medical history. One of the reasons why Paris became the center of medical training after the French Revolution was because of this access to bodies. In the early 1800's, American medical students were pleasantly surprised at the access they had to female bodies, esp. in midwifery hospitals. They never had that access in the US. Doctor's need to learn, and they need to learn with real bodies. How then, do you make sure you're not just treating a body, but treating the whole person, the whole human being? It's easier to just deal with the body. Much harder to deal with a real personality with likes, dislikes, preferences, values, etc. This has always been a conflict within modern medicine.I'll write more about this fascinating history in an article soon on my blog with Dr. Sherman. Doug

It is my opinion that having students perform a rectal/pelvic has much more meaning in medical school teaching of professionalism than having them perform inspecting the auditory canal cavity with an otoscope. The rectal/pelvic because of the intimacy of the exam compared with that of the ear should and will cause the student to stop and consider the patient more as a subject (a responsive human being with an anus and a vagina that will be entered) rather than the patient as an object bearing an ear to be entered. Because of the potential sexual connotation of the anus and vagina as compared with the ear, there will be more stress on the student to attend to professional behavior than examining the ear. I don't want to leave the impression that examining the ear with an otoscope is trivial and the ear is some inert structure to an inert patient which can be examined without humanistic considerations by the examiner, but the context of the examination is definitely different.

May I leave this commentary with a final thought? I would say that the rectal/pelvic exam should always remain part of the medical student's curriculum since it is my impression that when the student has survived this exercise, one exercise and procedure given the medical profession societal permission, they say to themselves "now I really feel I have become a doctor!" That may sound corny but maybe that is my recollection how I felt "back when". ..Maurice.

Dr. Bernstein is reminding me of the fact that when my son (who graduated medical school this May) finished his ob/gyn rotation, he called to express gratitude to me for having successfully given birth to him and his siblings. It made me smile because it seemed as though he could not believe that I could survived what childbirth had put me through. He was almost in awe and had a new respect for me and women(albeit it was somewhat short-lived as he has since moved on). He did not go into ob/gyn since this specialty was not his interest and it also seemed to me that the required ob/gyn rotation was not very male-friendly (which I can understand and agree with) although I think he may have felt actual hostility. He also accompanied a group of mostly women medical students to a third world country where their main objective was to educate women about family planning and test for disease and cancers. I felt that he came away from this experience with a true sympathy for women as he felt they had a very tough deal. I think the child-bearing, child-raising and work that the women had to do along with the possibility of getting venereal diseases from their husbands made a profound effect on him. I know he had to do some pelvics and papsmears but I think he had a genuine concern for the plight of the women in these remote and poor locations. I have seen pictures of the native women and children and the medical team which included my son. I don't think there would have been anything sexual involved in these interactions.

Here is a posting from Kristina submitted this morning. As you note below, I edited out names (my policy: no names) nevertheless it is a worthy commentary to the discussion here. ..Maurice.

I enrolled in a bioethics course my first year of under grad, which caused me to realize just how many ethical issues need to be confronted in the medical field. My infertility doctor at [a university medical center] did a surgical procedure, he always had students with him and I assumed they would just watch and occasionally check something out. Now im wondering what I signed up for in the consent form. However, I felt he was an astounding doctor and I would definitely go out of my way to see him again. I also had a surgery at a [hospital] I wasn’t put out correctly before I got to the OR and remember being slabbed onto the table like a piece of meat- bruised ankle the next day. I decided at that moment, I want to be different. But if this is how fresh and inspired students with integrity and compassion, who question ethical issues get treated? What does one do? Hope to make it through med school and still have it in you to be different?Thanks for this posting. I greatly appreciate this blog. It provides a small inside glimpse into the field, which will hopefully prepare me better for what is ahead.

But PT, SS was dealing only with the specific issue, which troubled her as a med student, of performing invasive procedures such as rectal exam in either gender or entering the vagina for a pelvic exam. She appeared to me just as personally concerned about the act of entering the anus of a man as well as a woman by a student or healthcare provider of either gender.

Someone please correct PT or myself if either of us misinterpreted what SS was writing about. ..Maurice.

I agree with your synopsis that SS was dealing with a specific issue and made it clear she was concerned with performing these invasive exams on either gender.

Beyond that, she describes policies and procedures that, IMHO, violate the rights of patients of both genders. She also unequivocally states that both genders should be able to choose the gender of the provider that is most comfortable for them, and should not be coerced into unnecessary exams and procedures unrelated to their reason for seeking care.

Yes she does go into greater detail about the medical abuses of women, but the reality is that women are far more likely to be coerced, intimidated or brainwashed into being victimized by these invasive procedures than men are. Sometimes it's almost like the medical profession treats being female as a disease.

I'm getting really tired of the "male vs. female - who gets abused most" arguments. The reality is that neither gender should be abused by the medical system, and it's time to quit whining and start working together to insure that all patient's rights are respected. There's a great guest Post by Suzy Furno-Maricle on Doug & Dr. Sherman's Patient Modesty and Privacy Concerns blog that addresses this. Look for "Gender Wars" - IMHO, it's well worth the read.

I'm getting tired of the lack of privacy issues and thediscrimination against men being pushed to the backburner . People have choices in this country and formany many years female physicians have been available for female patients. Yet, they choose a maleand complain when they get a pelvic. My advice, don't go to a male physician. It's thatsimple. Odd that I'd never read about any male physicianwho has groped as many patients as the female ENTphysician in New Mexico. That the female nurses stoodby in the operating room while this pervert groped all thesemen while getting surgery on either their ears,nose orthroat for years. I suppose they missed their class on advocacy. Womenhave plenty of options when it comes to healthcare andprivacy. Yet hospitals continue to have a 95 percentageof female nurses. No forum anywhere criticizes womenfor desiring to have females during a medical procedure. Review the comments on the blog,10 things all womenshould know about prostate cancer. These women whoby the way run this blog do so only for money and reallycouldn't care about privacy issues for men. They actually argued against men for seeking all malefacilities. Get a clue! I might add Maurice, it is you who create these genderwars by creating these one sided topics that falsely suggest women are at a disadvantage,when in fact it ismen who are discriminated against the most. You always seem to subdue the concerns for men byintroducing the clothes free people here who we all knoware men! Seriously, when was the last time you walked through a hospital. All you see are women, a sea of them. When was the last time you visited another physiciansoffice and if so who worked there? Who works at all theimaging centers, mammo clinics and endoscopy centers? Ever see male clerks at gyn offices and ask any obgynresidency program director about women residents outnumbering men?

PT I think you are way off base with your criticism of Dr.Bernstein. He has presented a forum for open discussion. Open discussion includes hearing opinions that are different than yours. While I have openly disagreed with him on certain items such as whether providers know or do not know, whether they get and seek special considerations, how significant context plays into this issue, but I have never taken him to downplay male vs female modesty. Understanding why we feel this way, or do not feel this way plays into this. I could not disagree more with Hex's contention that females are more victimized by this in the medical system as the shear numbers of support staff would logically say other wise much less the attitude. However I respect his right to say so and agree with him 100% a unified approach is best. We don't have to agree on everything. Dr. Bernstein did not create issue of male vs female, he only provided a forum for us to discuss it...which you obviously have taken advantage of as well as anyone else. It would be really easy for him to censor you, but he didn't. I think he deserve credit not criticism....alan

Right you are alan and I didn't completely read the last post. Mycomment was directed at Hexanchus,not Dr B. For that I appologize,often my emotions get the better ofme. However, I am firm where I standon these issues and I'll reiteratemy opinion regarding this deposedmedical student or whatever sheis. Her contributions would be betterappreciated in the real world ifshe kept her mouth shut and finishedschool. At which point she couldhelp be a real world advocate,ifindeed she does exist,which I doubt. The truth is many women can't anddon't see the big picture. They wantconvenience,privacy and only for themselves. By depriving men ofrespect for privacy,choice(discrimination) they get it,almostexclusively. Yet,they would be wiseto advocate for both genders as yousee the dynamics of equilibrium willeventualy play out. The dynamics of equilibrium thatexist in the physical world are alsoat play in the social and psychological sciences. Eventually,nursing gender will reach 50/50,itsjust the laws of economics and social change. The eventual increase in female physicians and male nurses comes new ideals and realizations. In the final analysis, fewer choices for women,perhaps fewer choices for everyone.

Good read Hex. "The truth is that the “Medical Modesty” gender war has to end, or neither will reap benefits for very long. If we do not defend and help each other we will simply be considered a fad: a temporary and unique ‘genre’ in the medical arena."We need to cooperate before we fade away. We can't allow ourselves to be a "genre" taken seriously for two minutes then get left behind.Good job Hex.

the conversation with ss is has a lot of diverse and interesting points. I find it interesting that we are willing to deny ss using the same arguments and feelings as we do as patients to plead our case. And we as patients denying to validate her feelings much the sam way the medical community ignores our contentions. I understand the situation is different in the fact that medical students do or should know what they willingfully enter into, something like a patient entering into a medical facility for a test. Do we not hear or see the same thing, we assumed you researched this and understood that we were going to....as far as her training, I have a dermotologist, great guy does a great job, never once has he asked me about my prostate, got a urologist, can't believe he didn't notice the spot of skin cancer on the side of my face, and my ENT guy..can you believe he didn't even ask about the cavity I had in my right molar. The point is there are areas where ss could practice that would not require her experience in penetrating a vagina or anus. Just because the system isn't set up to do this does not mean they should not, just like providing for patient modesty. Just because they do not provide same gender unless asked (if then) doesn't mean they shouldn't......alan

There’s no question that both genders have experienced mistreatment from the medical establishment. Being male and knowing of the disproportionate ratio of female to male techs and nurses, it’s a mathematical certainty that males are faced with embarrassing opposite gender situations more often than females. Do men care about this? Are they modest? Of course they are! We know that. So what can we do to make this better? My interest, and the reason I am a regular reader of your posts, is to learn what steps can be taken to best avoid and/or manage these situations. I had earlier posted several questions/scenarios requesting a reply from Compliance PhD to which I received no reply. Considering your knowledge and passion regarding this issue, I would be very interested in each of your thoughts to the following:

How do women protect themselves from a team of hungry medical students waiting for them to fall asleep as described by medical student Hilary Gerber in The article the unnecesarean? Is there any way that a husband can suit up and go with his wife into surgery to protect her? Or can we, as citizens, pay for a same gendered medical professional not affiliated with the hospital to witness the pre op through the recovery operation and serve as an advocate for us in our unconscious state? Can the whole process be filmed with sound for the patient‘s future reference? This whole thing is shocking, morally unacceptable and far beyond what is considered reasonable.

Regarding the post with the following excerpt: Women who decline pelvic exams and episiotomies receive them against their wills! How can that be when the law indicates that patients must consent to medical procedures. Medical procedures may not be undertaken without a patient's consent, absent unusual circumstances. Why can’t the patient refuse in these cases? Is this a situation where the physician feels the patient needs it and bullies them into it?

Regarding those aforementioned embarrassing opposite gender situations: If staff/physicians are placing you in an uncomfortable position whereas opposite gender exposure is eminent and you refuse demanding your privacy is respected, is the hospital completely within their rights with no recourse if they decide to discharge the patient rather than make a reasonable attempt to accommodate their gender request? If the patient is threatened with discharge what should they do?

Just to be clear, I never said women are more victimized by gender related privacy violations than men. I have been very forthright and consistent from day one on this blog that men have the absolute right to same gender care for intimate procedures if they so choose, and that any patient has the absolute right to refuse any provider or procedure that they are not comfortable with. My position has not changed one iota.

What I did say was "the reality is that women are far more likely to be coerced, intimidated or brainwashed into being victimized by these invasive procedures than men are." I was specifically responding to Dr. Bernstein's question in the post immediately prior addressing the invasive exams SS took issue with - pelvic and rectal exams - and I'll stand by that statement. Some simple facts:1. Only women get pelvic exams, which typically include both speculum and bimanual exams and in many cases a rectal and/or rectovaginal exam.2. From an early age (ACOG is now recommending young women have their first GYN appointment at age 12-14) women are intimidated & coerced into getting their annual "well woman" exams. 3. It's a process that in most cases informed consent is conspicuously absent from. Want hormonal birth control? Put your feet in the stirrups & spread em! Never mind that the exam is not necessary or in any way related.4. Barring specific symptoms related to a medical problem, men don't even get rectal exams until around the age of 40, and even then USPSTF does not recommend them.

Yes there are a myriad of other indignities and privacy violations that males are subjected to by the medical community, but that is not within the context of what we were discussing.

In the situation you describe, the hospital has three options:1. Accommodate the patient's privacy related request.2. Discharge the patient if their condition permits.3. Transfer them to another facility if it doesn't.

Warmouth, at the current time they are within their rights if you refuse treatment. That, has to change.

PT You keep talking about how all women are against male modesty. That is not the case although, it may be in your experience. I have said over and over that this is not a one gender problem.

You are sadly mistaken if you think women have it easier when a procedure, operation or the ER are involved. It's a major undertaking to get an all one gender team and sometimes you are better off in a smaller hospital.

Alan, regarding your statements about SS, there is a huge difference between what's she's going through and what we go through while the basis is the same. The difference is that SS can walk and choose a different career but we are dealing with our very lives, our health, our mental health. There's not much you can do to avoid that.

My feeling is that if a school has a curriculum that students should know what's involved from the beginning and make their choices based on that. The platform needs to be open instead of secret and if someone chooses not to participate, it is their choice. We have little choice.

Some of us would jeopardize our lives to preserve our mental health. That is the crux of the problem and the medical community is not a very ethical place when it comes to informed consent.belinda

"Progress is not created by contented people." A quote by cartoonist Frank Tyger which I think applies wonderfully to the struggle to address patient modesty and/or same gender care for intimate procedures. It can also apply to possibly changing the climate of medical school and the "hidden curriculum" therein. However, I still see this as an uphill battle that will remain so until and unless those of us who feel this way can either speak up more often in medical situations or recruit additional concerned individuals to this "cause". Because right now I feel like the majority of people are either not too bothered by the status quo or they are unaware that they can speak up or are unwilling to for various reasons. So, the way I see it right now is that the only way we as patients are going to get our needs met is to request what we want and stand by that request.As far as females getting more consideration for modesty than males, I can understand the argument because there is, indeed, more female nurses, techs, etc. but the question needs to be "how can we change that?" We can choose the gender of our doctor but in many cases we cannot choose the gender of the support team and that is when the issue arises. So I agree with the others on this blog who are trying to focus this discussion on solutions. It just seems that at this point those solutions are going to be ones that individuals will have to discover or find for themselves as I don't see a systemic addressing of this problem anytime soon. Jean

First of all, PT, there is no reason to be insulting to SS. She is a highly intelligent person who has put herself out on a limb by speaking out about modesty and the status quo. She has opened up dialog about heretofore taboo subjects. Secondly, I would like to hear some good solutions from you and the other angry men regarding these issues. Perhaps your angry rhetoric in this blog it is making you feel better but you are directing your anger at the wrong people. What do you suggest and what have you done to address this issue?I experienced serious privacy and modesty violations about a year and a half ago when I had radiation therapy. I wrote a lengthy letter which I hand-delivered to one of the chief administrators at the hospital and I mailed a second copy to the CEO. I requested a meeting with the administrator of the radiation therapy center. I came to this meeting armed with reports and documents that supported my claims. All of this was done while I was not feeling well at all after surgery and radiation treatment for cancer. AND, like SS, I put myself out on a limb. At the meeting with the administrator of the radiation oncology center and an offending radiation oncologist as well as an administrator of the hospital, the administrator acknowledged that many men were uncomfortable having to disrobe for radiation treatment in front of the female techs (I had male and female techs until I made a fuss). Why did none of them protest? Why was I the first person to have to go through the ordeal and stress of going up against the system? And, believe me, it was very stressful! They have made some major changes at this center because of my advocacy. I wish someone had spoken out before I was a patient there as the experience has left me scarred and damaged.

Thank you, Doug and Maurice for your responses. Doug, I also think like you that doing these exams does not automatically make better physicians. I have not read your blog or dr. maurice's blog before (There was a link directed here to the student's article on the Women Against Stirrups blog) but I'll look into the upcoming article you mentioned.

I remembered one more point I wanted to bring up. As a 23-year-old healthy female, (the same age as many med students) I did not know these exams existed. I only do because my sister had a terrible experience with the pelvic exam. I asked my boyfriend (older than me), he also did not know schematics of a pelvic exam – he assumed everything was blood-work based and never thought about it!! People I know from under-grad went to med school and I suspect some of them did not think about this either (esp the boys). Hope they are okay in school now. As I mentioned in my previous comment, I have always had strict rubrics outlined. If a school is unable to make sure students understand the curriculum, I think the fault lies with them. That is how I would have felt.

To SS: can you tell us where you grew up? The Women Against Stirrups bog discusses how women from other countries have more negative attitudes about pelvic exams and talk/encourage them less. In another note, unless SS is exaggerating about the abusive gyno, i wish there was action that could be taken against him. Personally I cant wait until this breed of gynos die off.

To PT: You say that "Her contributions would be betterappreciated in the real world ifshe kept her mouth shut and finishedschool." I think this is the EXACT reason why there are many ethical medical issues. As a medical student, you are trained to follow orders and not question the environment you are in. In the above story, SS questioned the breaking BFOQ patient modesty law. The reaction was extreme hostility and swift expulsion. This type of environment creates students who will not stand up for themselves, like the nurse in the embedded article who participated in the anesthetized un-consented pelvic exams. "keeping your mouth shut" only serves to create an environment of secrecy. If this student had 'kept her mouth shut' and not questioned her position, we would not have heard about the abuses of the associate dean of gynecology. What he is doing (withholding birth control until women agree to pelvic exams) is breaking the law!! And you would suggest for her to not report this. Plus, since she was not planning on becoming a gynecologist, there is very little chance of her being able to become a 'real world advocate'. I would also consider that what she is doing here on this blog (publisizing her story) would be considered being an advocate.

I also wanted to post Dr Sherman's response to my earlier question (it was posted on his blog):

As a physician who trained decades ago, I don't fully recall my reaction to the first pelvic exams I had to do. In contrast our school barely taught us anything about male exams, perhaps thinking that they were so comparatively simple that reading our text book was sufficient. As was the usual custom in those days, the first bimanual exams were done on clinic patients. I have no idea anymore whether they were told we were students practicing or not. Although all students have anxieties about these exams, I don't remember any students not being able to cope with them. That part of SS's story is a surprise to me. Still and all her examples are persuasive and it is clear that it is a recognized problem that is indeed kept hidden by schools. As described by SS, her treatment by the school was poor. You would think some compromise could be made for a student who was clear that her career path would take her into other areas. As a cardiologist I have not done an intimate exam in decades. Probably 30-50% of physicians in this country can say the same.I have ordered the book mentioned in the article, Public Privates by Terri Kapsalis and hope to get a better perspective.

Dear PT and everyone else on this blog: As long as full anonymity exists on this blog and most every other blog accepting comments from the readers, we have no idea of who exists and how that anonymous writer exists. It could be one individual with multiple pseudonyms presenting various viewpoints. And it doesn't even have to be a visitor since if the blog moderator is, in fact, anonymous, which, unfortunately, some have been in the past and ??currently, it could be the moderator who is writing the comments! (As a non-anonymous moderator--and I can be reached at the USC Keck School of Medicine--I can assure you my only writing here ends with "..Maurice." Writing abusive or ad hominem remarks to any anonymous writer is a futile, irrational act when dealing with an anonymous entity besides being unfair and uncivil if the actual object of the remark was known.

With regard to SS, yes..even after over a year of private communication to myself and Joel she still remains to both of us a (to me, "tragic") anonymous individual. (Yes, I suppose we could hope to identify SS if we did some Googling as SS has suggested.)

What can we do about this issue of anonymity regarding writers to internet blogs? Not really much, unless we required a identification or background check for each participant (such as present on a ethics listserv to which I subscribe). A major reason for not excluding anonymity is that for a "discussion" blog oriented to the general community, we would get virtually no participation without anonymity and therefore no true discussion. So.. we have to accept anonymity but to keep in mind that our discussions should deal with the issues presented themselves and in no way casually or automatically tie in the issue presented firmly to the one making the presentation. Again, it is all about the ISSUE and, I would say unfortunately, NOT THE ANONYMOUS WRITER! OK? ..Maurice.

Doesn't make sense for a female med student whoseplans are to specialize in obgyn to criticize an entirespeciality and those who work and contribute withoutcompleting it. That would be equivalent to a male nursing studenthaving an equal perspective, critizing female nursesand their unprofessional comments without at leastcompleting the program and then making an attemptto effect change. I once knew of a female nurse who while facing a failinggrade in organic chem,she was in pre-med, deliberatelyspilled fuming sulfuric acid on her hand. With the hopeof being dismissed from the class without a failing grade. If you know anything about fuming sulfuric acid,pouringwater on the burn does not immediately neutralize the acid. She suffered permanent nerve damage. The med student's excerpts say out loud, only womenshould be performing pelvic exams on women,I don'tlike what I see so I don't like this profession, job I'mabout to learn. Was she failing the program, her way of pointing her finger at a system that she could notcompete. Certainly, she had entered the clinical phase of her training and not once mentioned nursing staff or theirbehavior. With 95/5 ratio spells absolute unfairness,disparity and discrimination for male patients. I've read hundreds of excerpts from male nursing students whereby they have excellent grades,but becauseof their gender their enrollment is looked down upon. This is just a gateway for this type of behavior in afeminized health care society such as ours and it makesitself known with no male mammographers,no maleL&D nurses.

PT, if I am responding correctly to what you wrote, in the 2nd year, students are perhaps an hour or two on the clinical hospital wards every few weeks (in my medical school) simply to take a history and examine a patient which they then writeup the case for the class. They don't have or devote any or much time at all fully observing or interacting with the nursing staff or even the ward physicians. All that interaction occurs during their "full time" and daily duties in the hospital wards in their 3rd and 4th years. ..Maurice.

I believe the student clearly states that she had no plans to 'specialize in obgyn', in fact it states she wanted to 'focus on pathologies of the brain and nervous system'.

I also gathered the impression she was saying that women should have the choice of having a women perform a pelvic exam on them - not that it should be mandatory. I thought she was criticizing the school for berating female patients who requested female gynos.

Also, with respect to the discrimination of male patients, she mentions that students are NOT trained to ask 'do you prefer intimate care from a male of female provider, or do you have no preference?'. I feel she is arguing these questions should be asked to EVERYONE, not just women. I certainly think it would make for a more comfortable patient environment. Being able to choose the gender of your doctor without having to request it may help avert embarrassing and uncomfortable situations for both male and female patients.

PT is unfortunately a prime example of why we lose posters on this site. There is no reason to not believe SS was a real medical student. She seems to want to take the cloak of secrecy away in regards to modesty issues and while applauded by most here of course PT has to be insulting to her. People won't want to post here if berated and undermined. I'm not sure why you continue to allow it, Dr. Bernstein especially when you know quite a lot of what he puts forth as facts aren't accurate.

PT has been usually a satisfactory contributor to the discussions here despite an occasionally doubtful moment. PT hasn't as yet reached a point where posting rejection has been necessary. Sometimes a more controversial voice is necessary to make folks wake-up and present a counter-argument. ..Maurice.

" especially when you know quite a lot of what he puts forth as facts aren't accurate."

I have over 30 years of healthcare experience and as such I've always cited references referring to the statistics of mydiscussions. Quite frankly anyone could, witha little internet investigation cometo the same conclusions as I do. Please use an identifying pseudonym as Dr B requests.

Erica said

"I thought she was critizing the school for berating female patientswho requested female gynos."

Well,I've never heard or seen that but truthfully Erica,walk ina mans shoes and you'll hear thateverywhere.

Erica then said

"Being able to choose the gender of your doctor without having to request it may help avert embarassing and uncomfortable situatons for both male and femalepatients."

Really,I never felt that reallywas the issue,but again Erica,howdo men accomplish this when the nursing ratio is 95/5.Its the support staff, Erica. How about theurology clinics,neuro icu,medicalicu and so on and so forth. Many icu's are 100% female nursing staff. I know of no maleassistants at any gyn,urology clinicmammo,L&D. What if your world got alot worseErica, if you woke up one morning tolearn there were only male mammotechs and male L&d nurses and that the the nursing ratio was 95% male. What would you do then? Welcometo a male patients world.

This site shows a cartoonish nude women being abducted by an alien and examined nude on a table.Now I would very much like to know ifthis is indeed true. Mostly womenhave reported this happening to them. It would lay truth to my belief that a) Advanced life exists in the universe and that yes,some have beenable to breech Einstein's theory ofthe space-time continuun.

PT, you have a point and I do get it. I went into surgery with a male anesthesiologist, a male gyn/oncologist (there are only male gyn/oncologists at our hospital and a male orthopedic surgeon, after having gone through radiation therapy with male radiation oncologists. I have to have some further pelvic surgery due to my previous treatments and the only surgeon who does this type of surgery at our big urban hospital is a male doctor. So, this doctor will do the surgery but I have requested female assistants, a female anesthesiologist and ONLY female residents if I have to have a resident in there at all. In the future, I plan to ONLY go to female doctors unless I absolutely can not avoid it. So, I do get it and I realize that I will probably have better success in the future of getting all female health care than a man would. I would not be happy about that and can understand why you are not.....Gail

" at the current time they are within their rights if you refuse treatment. That, has to change."

Here's what patients need to understand. To refuse having opposite gender care for a particular exam or procedure, IS NOT refusing the exam or procedure. Make that clear to caregivers. Say, "I'm not refusing treatment. I'm demanding respectful, dignified treatment that coincides with my beliefs and values." You'll see that right in some patient rights and core values documents. Make sure you read and have with you a clinic or hospitals core values, and patient rights documents. ALso, make sure they don't write on your chart that you refused treatment. If you suspect they are writing that, ask to see your chart. The key is -- don't refuse treatment. Make that clear. Doug

Hex I stand corrected, I applied the broader definition of invasive exams that many on this blog apply, that being disregard for modesty in general not just digital penetration. You obviously were referring to ss's reference to penetration. In the broader sense of the concept I would argue men are indeed more likely to be coerced into accepting having their modesty violated. I would put forth women seeking same gender providers will be recieved more openly than males dut to not only attitude and perception but shear numbers. I have read several accounts of female urologist using female assistants for male patients, does anyone believe a male gyno would use a male assistant even if available? Not trying to revive the battle of the genders, again I feel united we stand.I do however agree with those who felt ss's writings were slanted toward the female perspective, esp. in the begining, while I feel she came toward the middle as the article progressed there were numerous references to sexism as the basis of these issues. The truth is both genders face these issues in different forms. That said, I still say is it that hard to see the possiblity of in todays world of medical specialization a medical student becoming a doctor in a specific area that would not requrie they have experience in the specific acts ss found unacceptable. Should my dentist be required to know how to put braces on or be skilled in oral surgery? While I am a little dumfounded that one would enter medical school without suspecting this would be part of it, I still support her right to enter into a field and not do this if there is no real valid reason to do so other than...becasue we always did it that way.....alan

Oops! I erroneously blocked publishing Erica's comment from today but here it is in full. ..Maurice.

Hi Pt,

I have decided to respond to your posts in an organized fashion.

Part 1 (a) "well Ive never heard or seen that buy truthfully Erica, walk in a mans shoes and you'll hear that everywhere' about my comment that "i thought she was criticizing the school for berating female patients who requested female gynos". I only say this because of the testimonial of SS: that patients who requested female gynos from BFOQ law were berated into being too scared to ask for what they wanted (female gynos). I believe this law SHOULD be extended to include male patients

Part 1: Yes!!! I totally agree that nursing should be a 50/50 staff!! (and I hope that some day it will be!) However, until our (AMERICAN) society begins to view our male nurses as ACTUAL members of society (as opposed to MD failures), it is hard to rectify that imbalance. Male nurses are shunned and mocked and ridiculed (I know because I had multiple male and female friends in the RN major at my undergrad). I do not think it is fair to consider male nurses as 'gay' or 'too stupid for an MD' or any other insult other people intended (these are the insults I heard). I would (and still do!) hope for a more gender-even balance in physicians and their staff (techs, nurses, etc).

Part 2: I'm sorry, your link did not work for me. (however, after removing the two slashes it did). The website you are referring to is from 1998 (with examples from 1957?). If you are trying to trap me into a zany website which Women Against Stirrups supports, I can state that, though I support the main tenets, I do not necessarily agree with every argument. I am sure I could show you sites from 1998 that support my cause too! I do believe many women who observe themselves (laying passively) being examined by gynecologists (NOTE that I mean not necessarily men! I believe WOMEN can be abused by fellow women, just as I wholeheartedly believe men can be abused by women nurses) feel themselves being abused. (by the way you only mentioned part a and not some part b. I am not sure if this was intended on your part or not). What I meant in my previous comment by 'choosing the gender of your doctor' meant that if it was an intimate exam, you SHOULD be given the choice whether male or female....and NOT just to the physician, but ALSO for the staff. Thus, if you requested a male physician, you would ALSO be given male nurses and technicians. I did not mean to sound like I was disagreeing with you: I agree that men's patient modesty is as important as female modesty ('feminized' health care means equal health care, not skewed to favor women)! Is there a way to end the disparity between females and males who choose the nursing field? If anyone has any suggestions, please make them known.

Here is today's comment from Warmouth. To keep to my policy of not naming names or allowing potential commercials here, I deleted the name, address and link of Warmouth's urologist despite his complimentary remarks about the doctor in Florida. Warmouth can post here his e-mail address for those interested to obtain the details regarding the doctor but off this blog. {Sorry to be so strict but I would like to maintain my blog policy.) ..Maurice.

PT: In regards to your post in pertinent part, "I know of no maleassistants at any gyn, urology clinic."

I was recently referred to a urology clinic by my family physician to determine if I needed a particular procedure. My family physician is aware of my modesty issues and as a result, referred me to a specific urologist known to be sensitive to male modesty. Thank God I didn't need the procedure but it gave me an opportunity to meet and talk to this urologist. He explained to me that he looked at his practice as a business and his patients are his clients. Obviously, if he unnecessarily humiliates, harms, or angers his clients in any way, they likely won't come back and that's bad for business. Although his staff are mostly female, he employs at least one male tech (for those who request it) for procedures that can be done with one tech such as preparing for a stint removal or vasectomy (Both very embarrassing but not a big deal if gender specific) He also hires a male x-ray tech several days a week for those male patients that want a male x-ray tech. I also had the opportunity to talk to a female tech and the female staffer who schedules procedures. Both firmly indicated that they completely agreed with a man requesting gender specific care and indicated that they want the same for themselves. I can’t say for sure that everyone there agrees or whether in a very involved procedure like seed implants if there is any possibility of an all male team but I can assure you that the staff at that clinic have been briefed/trained that male modesty is a concern and that it is to be regarded. This experience, while not resolving the medical gender staff imbalance or the modesty gender war, certainly made me feel much better and gave me much respect for the urologist. It shows that there are some isolated places out there where we can go and at least have hope of some preservation of dignity. Perhaps this urologist was a victim of medical humiliation himself at one point. This brings me to another point where I agree with you PT that SS could have went on to complete her training, got her MD and then been a champion of patient rights. That would have been a better read.

We're on the same page. Overall, I agree that men undoubtedly get the short end of the stick from the medical industry when it comes to respecting their modesty and privacy, but as Gail points out, it happens to women too. We've hashed over the "why" endlessly on this blog - the problem is still the "how" to fix it. I believe that there's a pretty good consensus of constructive ideas that have been presented here - beyond that it's going to take time and continued pressure from patients to effect any real change.

I'll accept that some of SS's writings might appear to be slanted toward the female perspective, but I believe there are valid reasons for that - not the least of which she is a young female and viewing it from that perspective. Additionally, when she objected, she was ultimately referred to the head of OBGYN, so her experience was contextual in that respect as well. In fairness though, she was just as abhorrent with regard to rectal exams performed on male standardized patients.

I guess what I'm suggesting is that we need to realize that those influences exist and look beyond that. IMHO, regardless of her perspective, SS has provided valuable information from an insider's point of view that validates much of what has been discussed here ad nauseum. Ultimately that can help us effect change if we use it to our advantage.

Hexanchus said : "SS has provided valuable information from an insider's point of view that validates much of what has been discussed here ad nauseum. Ultimately that can help us effect change if we use it to our advantage."This is a valuable point. A few blogs ago we were discussing students: was patient modesty ever considered, were our bodies an entitlement that they assumed upon entering the field, were these issues slowly drained and replaced by other issues? The goal was to see if we could affect them when we still had the opportunity, or maybe: IF we did have the opportunity. Students have largely been portrayed as beings who step foot onto a campus and somehow selfishly lose all rational consideration regarding anyone's modesty but their own. It seems that's not always true, because “SS” later speaks of the realization of patient modesty as well. Could she have ‘sucked it up” and later become a strong advocate for patients? Could the institution have found a way (as some doctors do for some patients) to make this procedure palatable for her? Those opportunities are now missed, and I have to wonder if there is a way to catch them before they all fall away.Regarding anonymity: I think most of us believe there are separate and real human beings behind every post. (Except the times we forget to sign).The only way to know for sure is if everyone ‘came out’ and I don’t think it is fair to expect that. I did because I saw no reason not to, and (for me) advocacy and anonymity did not mesh. Others do it quite well, and we have to respect that choice. I have family members at home who occasionally post here. Some agree with me: others don’t. I have no rule that they must declare who they are (just please do not use my name), although selfishly I would much rather have the face to face honesty from them.The big “except” for me is that: I believe that anonymity is what keeps us from forming a cohesive group. I still have hope that this too will change.

I agree with Hexanchus' post regarding looking at ways to "fix" the patient modesty issue for both men and women: that it will take time and continued pressure from patients. With that being said I don't see any change occuring until there are enough patients pressuring medical institutions about this. In other words if we are, indeed, a fringe group no one is going to consider our concerns big enough to justify a system-wide change. It will still have to be only an issue we as individuals can address to get the care we consider respectful. I also noticed a comment by Suzy about her friends and family either agreeing or not agreeing with her on this issue. It made me wonder if other posters here have brought this up with their family and friends to see where they stand on things. Until we can "recruit" more people to this cause it still seems like we are a small group. The posters here tend to be the same ones over and over with an occasional newbie who doesn't always stay for long. I think there is strength in numbers and the more people we can get to address this issue when they go into the medical arena the more likely we will be to see major changes. Jean

With regard to the issue that SS brought up with regard to what a student entering medical school is told to anticipate as the pre-requisites for graduation particularly in regard to issues of physical examination, I think I found the answer. The answer is, of course, only pertinent to the medical school where I teach: University of Southern California Keck School of Medicine and is found in the publicly available Student Handbook, presumably to be read and accepted by all candidates planning to apply to Keck.

Here is the description of the Physical Requirements (page 38}:

I. PHYSICAL REQUIREMENTSAfter reasonable training and experience, the candidate must be able to observe and participate in demonstrations and experiments in the basic sciences, including but not limited to dissection of cadavers, examination of gross specimens in gross anatomy, pathology laboratory and neuroanatomy laboratories, preparation of microbiologic cultures, and microscopic studies of microorganisms and tissues in normal and pathologic states (e.g., streak plates, perform gram stains and use a microscope) necessary for such studies. Observation of gross and microscopic structures necessitates the functional use of the senses of vision and touch and is enhanced by the functional sense of smell.After reasonable training and experience, the candidate must be capable of performing a complete physical examination, including observation, palpation and percussion and auscultation. The candidate must be capable of using instruments, such as, but not limited to, a stethoscope, an ophthalmoscope, an otoscope, and a sphygmomanometer. The candidate must be capable of performing clinical procedures such as, but not limited to, the following: pelvic examination, digital rectal examination, drawing blood from veins and arteries and giving intravenous injections, basic cardiopulmonary life support, spinal puncture, and simple obstetrical procedures. The candidate must be capable of performing basic laboratory tests, using a calculator and a computer, reading an EKG, and interpreting common imaging tests. The applicant must be able to move in the clinical setting so as to act quickly in emergencies. At the conclusion of the Introduction to Clinical Medicine course the student will demonstrate proficiency in the skills described above. By the conclusion of the clinical clerkships the student should achieve full competence in the skills described above including the ability to synthesize and organize these skills.

So it's all there for the reading!Now, I am not referring to any other medical school except USC Keck but I can' imagine other schools would not describe for potential students what is expected. Those who have time, read through the Handbook and see if there are other points pertinent to the discussions here. ..Maurice.

You know, I just thought.. perhaps Joel can look up from his medical school what the current Student Handbook says about what is to be expected.. and maybe he can also research what the former medical school of SS says in their Handbook. ..Maurice.

Last week, an article appeared in a local newspaper announced a preseason sports clinic for high school athletes that will be run by a local medical center. This article provides a good example of why we need to be proactive if we are to make inroads into achieving consideration for patient modesty needs.First, there is absolutely no mention of the gender of those who will be conducting the physical exams or whether or not a participant might have any choice regarding the gender of that provider. I believe this makes it clear that to those operating the clinic, gender should not matter in medical exams, even though both patients and providers clearly know that it does.Second, those who wish to attend the clinic are instructed to download an INTERSCHOLASTIC ATHLETIC ASSOCIATION approved medical exam form to bring with them. The physical exam portion of the form asks, among other things, about the heart, pulse, lungs, abdomen and genitalia. The odd apart about this is that only after “genitalia” do the words “males only” appear in parenthesis. Why is it that only young men are subject to these intimate and embarrassing exams while the young women are not? Are they checking for hernias? If so, aren’t women subject to hernias as well? This appears to me to be a classic example of the double standard regarding modesty so often found in the medical field.Therefore, I believe that it’s important that we adults work to protect our sons from embarrassing and unfair treatment by the medical profession by insisting on the availability of same gender providers and equal treatment for both males and females who wish to participate in athletic programs.

To Warmouth.It's refreshing to hear something positive about male modesty.Your urologist sounds like he has his patients best interests in mind.He knows if he unnecessarily humiliates,harms,or angers his clients,they likely won't come back.Very true.I also have a comment for MG.You have a perfect opportunity here.Call the clinic and ask if they have male staff for the boys physical.If they say yes,problem solved.If they say anything else,ask why not.Tell them why you won't be using their clinic,and you will not recommend them to your friends and family.If they are part of a larger group,call the administrators and tell them the same thing.Then have your wife call and do the same thing.We all need to do something in our own little way.They hear us,but they choose not to change.After all,it's their playground and they don't like you making the rules.Just another thought.I consantly read about the nurse/tech ratio.5% male/95% female.Since 90%(a guess)of what they do is above the waist,I believe most males could care less who does it.We only care about the lower 10%.Some don't care about that either.Enter Compliant PhD's suggestion about the male hit squad to be available when needed..All we need is for them to get the message.Take away the money,they get the message.No patients,no money.Trust me it works.Take Care. AL

It depends on the type of hernia. Inguinal hernia is almost exclusively a male problem - stats show the incidence rate in males is almost 10 times that of females. they also show that the incidence decreases with age.

Usually these are discovered and corrected at an early age. There's a lot of consensus that the sports physical genital/hernia exam is of little or no value.

I agree that all patients, including kids, should be able to choose a provider of the gender they are most comfortable with.

Sorry about that - I got absolutely buried on a couple work projects the first half of the year, and I guess I forgot to post an update.

My niece is just fine & feisty as ever. In fact, a bunch of us, including her, are headed out on a diving trip Labor Day weekend. Hoping for some good shark photos - wish us luck!

As we expected it never went to trial. The LPN and CNA involved negotiated a plea to a lesser charge of harassment & it got bumped to an ALJ for disposition. They got probation, community service & mandated "sensitivity" counseling, whatever that is (probably some seminar). If they keep their noses clean for a year it gets expunged from their records. There was also some kind of informal reprimand or probationary action by the licensing board, but I don't know the details. I highly doubt if either of them, or anyone they know or work with will ever do something like this again.

The medical facility wrote a very nice letter of apology and promised to take action to insure it wouldn't happen again. They are apparently including instructions on a patient's right to say no and have that respected in the policy training all employees have to do on a periodic basis - don't now the details so I can't comment further. Don't know what, if anything happened to the intern. He was never directly involved, and anything they did would be an employment matter, the confidentiality of which is protected by law.

That's not true, PT. I've had an IVP done in my urologist's office. Call around Warmouth to the bigger urology offices and see if they are full service and what they do onsite. My urologist also does cysto in office as long as you don't require general.

Generally, a piece of equipment must generate moreincome than it costs. X-ray machines take up a lotof room, the walls must have a thin layer of lead installedand you will need either a wet processing system or digital. With digital comes the added expensive softwarecosting easily over a million. The three most commonly requested medical imagingexams from a urologist are a CT Urogram(cat scan) or CT abd/pelvis with and without contrast and a voiding cysto urethrogram.. Ivp's are antiquated and often replaced bythe cat scan. The more expensive x-ray machines comewith an added feature of fluoroscopy which is usuallyreserved for radiologists. X-ray suites are extremely high maintanence equipmentfactoring in failed tube costs,processing, x-ray salariesand insurance. The reimbursement is just not there! Urologists are among the lowest paid of the surgicalspecialities and as such I know of no urologist anywherewith his own x-ray equipment. It would be a losing moneyproposition. Basic x-ray equipment does not deliver the needed diagnostic information in real time. You need fluoro andor three-dimensional imaging(cat scan). With a basicx-ray machine you are limited to an ivp and kub. Most Urologists are in solo practice and even multiplepartner practices would never consider on site imaging.

You should be careful of making such blanket statements, PT. You first stated no urologists do x-rays and now realize that isn't accurate. Please be careful in how you present your information. My doctor's office does x-rays and cystos in office. I'm sure they're not the only ones out there that do. It's a large practice so they must make enough to cover the costs. It's also much easier on patients. I was happy that I could go to the office versus the hospital. It' well worth making some calls.

Tell me cm, you had an ivp,which stands for intravenouspyelogram. For this procedure, you have an iv startedusually on the hand or arm. A contrast media is introducedand a few abdomen x-rays are taken over the period of 20 minutes or so and that's it. What would be the difference at any other facility, be ita outpatient facility,hospital,etc. It's all the same and it'snon-invasive and essentially one of those proceduresthat is irrelevant of the gender performing the procedure.

I've known hundreds of Urologists over the years andwas actually at a Urology convention once on the eastcoast.Never ever knew one to actually have their ownon site imaging for the reasons mentioned. In the 70'sand 80's an ivp was the state of the art procedure for a basic evaluation of the kidneys,ureters and bladder,hence kub with contrast. Cat scan is a much better diagnostic tool besides, generally on the type ofinsurance the reimbursement rate for an ivp mightbe as low as 75 to 100 dollars. You have to do many of those a day to pay for theoverhead, it's not worth the output. Additionally, you don'tsee a large volume of patients and therefore the equipment cost cannot be justified.

PT, first just a correction to the use of the term "non-invasive". An IVP is invasive in the sense that a dye is injected into the blood stream and while most times the patient will tolerate this contrast media, some patients suffer complications or death because of allergic reactions or direct kidney failure to the dye or rarely some diabetics on metformin will experience lethal lactic acidosis reaction to the dye.

Second, to PT and all: let's end this discussion of the economics of radiologic procedures since, as moderator, I think, in a way, it's off the topic of this thread. Now whether one wants to discuss the ethics of having a panoply of radiologic equipment in a doctor's office in contrast to referring to some outside source where the doctor has the potential of no economic benefit.. ahh! that would be a great ethics topic to discuss on another thread. But not here.

I hope I am not too critical in my monitoring of the course of conversation here but at least I want to demonstrate I am reading and moderating. ..Maurice.

The point I wanted to make was this, invasive meaningAn exam such as cysto, which requires a foley. The real point I was going to get at eventually wasthis has nothing to with the relationship between a urologistand an x-ray machine,but rather Urologists don't hire Males at their clinics.

Certainly, estimated creatinineclearance should be on the list youmentioned before iopamidol injections are involved.

Additionally, each state has their own agency regarding thelicensing of x-ray machines. Withtime I could determine how manyurologists state by state have theirown machine. Is it worth it to me,no. It just that I doubt any havetheir own let alone a few,besides there are no benefits from a privacy standpoint. Often,comments are made on thisblog attesting to accomodations for men that are simply untrue and unrealistic.

I feel I must comment that this article is about female modesty, not male modesty. This does not mean that male modesty is not important, but the student did not directly see male abuse by female practitioners, whereas she saw female abuse by male practitioners.

I just read through some of the past comments on SS's article here, and on July 15, dr. maurice posted a link where Hexachnus directed members from another blog (critics of pap smears) to read SS's story. The link dr maurice provided is: http://blogcritics.org/culture/article/unnecessary-pap-smears/comments-page-109/#comments

It looks like a member "Mary" ACTUALLY LEFT this blog b/c she couldn't stand how female modesty concerns were attacked constantly. many commenters on the site were repulsed by SS's description of the director at her school. why then PT do you disregard SS revealing how abusive gynos who teach future gynos are? that is important and relevant to her perspective ... I think it is important to discuss male and female modesty. I do not think we should favour one gender over the other. Just because we are currently discussing female modesty issues does not mean male modesty issues are not as important. It just isn't as relevant to the current discussion.

these are some of the comments from july 12 on that website regarding SS's story (read "Mary" opinion of "PT"):

Jacqui (Australia)"Hex, that was very interesting reading. No wonder the gynos of today are such toads, if they are taught by such wonderful specimens of humanity. Thanks for the link."

Mary (Aus)"Thank you Hexanchus for that link. It was a great read. What a pity that student will never be a doctor. I stopped visiting that blog ages ago becaue I got sick of "PT" dimissing every female complaint of modesty issues. (eg denying that women in the past found it difficult to find a female gyn etc)"

Alison (Aust)"Thanks also Hexanchus. I think it's appalling that people who want to study medicine are indoctrinated into this elitist culture, whereby dishonesty and arrogant disrespect for their patients personhood is encouraged. The ex medical student who posted would have made good and compassionate doctor, it's a shame that ethical people are being weeded out of the medical establishment before they even graduate."

Dr. Bernstein, Please allow me to make a comment regarding the x-ray machine at the urologist’s office that I referenced in my post of Tuesday, July 26, 2011 10:29:00 PM.

This post seems to have upset PT and his post in pertinent part, “Often, comments are made on this blog attesting to accommodations for men that are simply untrue and unrealistic.” I believe was directed at me. Consequently, I phoned the urologist’s office today and asked about the x-ray machine. This is what I was told: “We do have a CT machine and the CT tech is male. He is the one who the doctors also use for clinical procedures when a male patient insists on a male tech.” That’s what was told to me. Furthermore, what I posted Tuesday, July 26, 2011 10:29:00 PM. was what the urologist told me face to face and I actually saw the male tech that day busily walking down the hall. I also called four additional urology clinics in the Gainesville, Fl. Area and found one of the four utilizes male nurses.

Now those are the facts and I don’t need to make up stuff for my entertainment. If PT doesn’t believe it, then there’s not much I can do but if he can post his e-mail, I’ll send him the information on the clinics and he can call them if he would like.

Now in closing, do I think the Dr. really understands modesty or cares about the patient? Maybe a little but he probably is just trying to be a good business man.

Do I think there’s a double standard in health care. Absolutely.

Do I think a female should work in a male urological clinic? Absolutely not (I think they’re sick perverts that want to look at and handle male genitalia as well as have the power of humiliation over the sick male patient. I hate them all) nor do I think a male should be anywhere around a female clinic for the same reason.

Do I think I have a very good chance of avoiding humiliation at this clinic? Maybe but eventually I’ll be exposed like everyone else or I’ll choose to die instead.

My point was at least the physician made some effort and his staff seem to care at least a little. That’s a lot more than most of the experiences I’ve read about on this blog. I’ve had some bad experiences in health care but I just thought it fair to write about the good experiences as well.

"A good medical student who goes on to become a good doctor learns not just the importance of the exam but the importance of good communication in regards to them as well."

I could not agree more, Anonymous. Hopefully my article persuaded you and other readers to avoid graduates from "my school" because they do not encourage (but actually discourage) students from honest communication with patients:

1) "My school" shuns students who legally ask patients if they prefer same or opposite sex intimate care.2) "My school" teaches students to give pap smears to all women, including virgins, without telling them it is harmful given their risk levels.3) "My school" and its OBGYN Dean encourages students to lure women into unnecessary and humiliating but lucrative exams for BC.4) "My school" instructs students to lie and call themselves "doctors" so patients will "trust" their skill levels.5) "My school" trains students who cannot cope with the exam that it is better to not admit so and then cry on unsuspecting patients.

A good medical school that goes on to train good doctors knows the importance of good communication.

"I find the thought of non-consensual intimate bodily penetration of anaesthetized persons by multiple medical practitioners, and particularly students, to be completely abhorrent. On the other hand, I really have difficulty understanding that someone entering into an MD degree course would not comprehend, without specific spelling out, that this requires a complete familiarity, theoretical and practical, with all aspects of human anatomy including internal examination of mouth, nose, throat, ears, rectum and female genitals.

Even if you admit you have difficulty understanding people from different backgrounds and background knowledges than yourself, do you have difficulty respecting that they deserve informed consent over your hasty assumptions?

I think your back-to-back statements are hypocritical. You implied consent in medicine is important (at least with your expressed disgust over what happens to anesthetized patients). Why then do you at the same time not believe full consent is important for young medical students when they are known to have issues? Your statement is as rash and creepy as teaching hospitals assuming their vague consent forms do not need to spell out to patients that allowing medical students to practice exams on their bodies includes pelvic and rectal exams under any conditions.

It is ignorant for you to speak about the medical knowledge of all incoming young students from various backgrounds than yourself even though you have never met and discussed the topic with them all, and then use your unfair generalizations to oust any students like me as "clueless" and hence unworthy of informed consent. As someone who did discuss the topic with medical students and faculty, I can tell you your assumption is false. And I know you did not provide us with any reference to support your assumption because you could not find one.

"Whatever the career plans of the student, ideas or circumstances may change and if a qualification entitles a person to exercise as a general practitioner who may be faced with anything at all then they should in my view have completed the entire curriculum."

A "general practitioner" is defined differently across generations, and across countries. Where I am from, a pelvic exam is for gynecologists, not for "general practitioners". Pelvic exams are not part of "general physical exams" and that is why many women never submit to them. Hence another need for thorough explanation to applicants what a "general practitioner" does in America.

"I am sure there are plenty of other professions where people who would love to join them have to abandon doing so because of an inability, whether physical or other, to complete the curriculum."

There are blind medical students who cannot complete the curriculum because of their "physical inabilities". After they graduate, they avoid fields like biomedical imaging.

It is likely the young female student who had history of sexual abuse did not know what a prostate exam was beforehand. And if she was abused before matriculation, she could have realized she had a "psychological inability", if that is what you suggest it is, with the curriculum. But "my school" did not even give her that opportunity.

Regardless, I think the most destructive "inability" for medical students belongs to those who disrespect patients, enough to mistreat and even rape them as has been the case for decades in medical schools.

Thank you Doug, for all those relevant references. It is encouraging these authors are trying to demystify the problem. Before I left, I handed the article "Managing Emotions in Medical School" to faculty at my school, although I suspect it quickly found itself in pieces at the bottom of the shredder.

"People I know from under-grad went to med school and I suspect some of them did not think about this either (esp the boys). Hope they are okay in school now. As I mentioned in my previous comment, I have always had strict rubrics outlined. If a school is unable to make sure students understand the curriculum, I think the fault lies with them. That is how I would have felt."

Thank you Erica, I would be interested if you could ask your friends who went to medical school, if you do not feel nosey about it. It would not surprise me if some of them did not understand these exams. When I brought the topic up with my roommate, a resident who attended a different medical school than I did, she confided in me she also did not know what prostate exams were when she entered medical school. Although she did know what pelvic exams were because she had received them. She agreed with me: "How would you know?" This roommate actually worked as a CNA prior to medical school as well. I really do not think all young men and women know about pelvic exams and prostate exams, and the conversations I had with people confirmed that.

"So there is a great likelihood that many of the international students also do not know about these exams prior to entering medical school."

I am not an international student because I have American citizenship. And culturally I am quite American because I was raised by American parents and switched into an American school system in eighth grade. I do not think it is only international students who do not understand these exams, but definitely agree with what you say, that they might have less of a chance of knowing and valuing these exams in comparison to American students. (Read article: Cervical Cancer Screening Among Female Medical Students in Japan and the U.S.)

"To SS: can you tell us where you grew up? The Women Against Stirrups bog discusses how women from other countries have more negative attitudes about pelvic exams and talk/encourage them less. In another note, unless SS is exaggerating about the abusive gyno, i wish there was action that could be taken against him."

Thank you for asking but I am not comfortable revealing where I grew up on the public forum. Please e-mail me and I will tell you. I definitely agree with you about cultural attitudes shaping how people respond to these exams. I retrospectively learned that pelvic exams on healthy women is a concept not much short than an unfunny joke where I am from. Believe me, I am not exaggerating about the abusive gynecologist at my school, and I am reporting his birth control philosophies to the LCME.

"I'm getting tired of the lack of privacy issues and the discrimination against men being pushed to the back burner. People have choices in this country and for many many years female physicians have been available for female patients. Yet, they choose a male and complain when they get a pelvic. My advice, don't go to a male physician. It's that simple."

I agree with you PT that medical BFOQ issues for men are pushed to the back burner. The medical community has responded more to popular female BFOQ concerns (according to Dr. Shermans's Blog, as many as 90% of young females prefer female care) as evidenced by the prevalence of all-female OBGYN clinics, whereas all-male OBGYN clinics, all-male men's health clinics, and all-female men's health clinics remain almost nonexistent. According to men on these Blogs, all-male men's health clinics would also be appreciated, and so obviously their BFOQ interests have not been actualized by the medical community the way they have been for women.

I disagree though with your advice that if women simply avoided male physicians, it would resolve the atrocious misconduct in women's healthcare today. Some male gynecologists are better than some female gynecologists, and some female patients actually prefer male gynecologists or have no preferences. So I do not think the problem is that some gynecologists are men.

The problem is that gynecology was invented by primarily male minds that did not care about women, and that the misogynistic theories and practices they cultivated are still being handed down to future gynecologists. The reigning gynecologist Dean at my school does not support patient legal rights to choose between male or female providers, as well as patient legal rights to obtain BC without confronting conflict of interest. The tragedy is that future gynecologists are directly learning from despicable people like him, and passively learning from medical textbooks written by and national guidelines decided by despicable people like him. It does not matter whether this Dean was male or female (although I did point out that he will sadly never get a taste of his own medicine because no physician will withhold Viagra from him the way he holds BC from his own patients). What matters is that the damaging mindset of this person will trickle down to future gynecologists.

"Doesn't make sense for a female med student whose plans are to specialize in obgyn to criticize an entire speciality and those who work and contribute without completing it."

Please read the article: "I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology."

"Certainly, she had entered the clinical phase of her training and not once mentioned nursing staff or their behavior. With 95/5 ratio spells absolute unfairness,disparity and discrimination for male patients."

I only completed one year of medical school and did not enter the clinical phase of my training, which begins third year. My only exposure to the hospital environment was six half-day mandatory experiences with a pediatrician and his pediatric physical therapist friend. I was never exposed to the environment where these intimate exams occur.

Please read the article and comments:

1) In my very first comment, directed to Anon52, I did mention the shortage of male nurses: "The first time I saw boys/men voicing modesty concerns as loudly as girls/women was on Dr. Sherman's Blog. I was disgusted to read what some of these patients had been through. It was obvious many of them were silenced and oppressed, unable to make modesty requests lest they be branded unmanly and sexist to prefer same or opposite intimate care. It was also evident the shortage of male nurses contributes to the problem. Because of this, I was puzzled my school enforced the "one female in the male rectal exam" policy because many male patients blogged about feeling traumatized to have females present during their exams. Another sloppy gap between what students learn and what patients want."

2) In my previous comment to you: "Thank you for your statement about nurses also being responsible for "gang rape" of patients. It is disgusting health care providers from all areas are so viciously brutal toward their own patients... I can only write about negative aspects of medical training regarding "intimate" exams from a medical student perspective, but hopefully more nurses will write about similar topics from their training as well. It definitely needs to be recognized and changed as soon and completely as possible across all fields. There are no excuses for health "care" providers to do this to the people they "care" for.

There were other times in the article and comments where I addressed reported bad behavior of nursing staff, even though I only directly witnessed abusive physicians in medical school:

3) "The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education."

4) "When we read stories of doctors (and nurses) abusing patient rights during intimate exams, some of it is because of behaviors fostered in schools."

5) "And today, humanitarians are beginning to fight for recognition that rape can occur in the medical setting. Right now, the assumption is that doctors (and nurses) own their patients (hence they can gang rape them without going to jail)."

6) "Maybe the "shock value" of physicians and nurses abusing patient rights (disregarding BFOQ, withholding BC from pelvic exams, and medical "gang raping") has warn off for people, but the "shock value" of a medical student finding these exams violating even in the "safe environment" with actors is entirely new and, as far as I know, never previously admitted as publicly as this forum."

And I did generalize to defend all patients from what I specifically witnessed in medical school, which was two male physicians disrespecting female patients:

7) "Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgements on their patients and their sexual values and identities."

8) "On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well."

"But if this is how fresh and inspired students with integrity and compassion, who question ethical issues get treated? What does one do? Hope to make it through med school and still have it in you to be different? Thanks for this posting. I greatly appreciate this blog. It provides a small inside glimpse into the field, which will hopefully prepare me better for what is ahead."

I cannot determine from your writing whether you are a future medical student? Because I did not write this article to deter people from entering medical school! (Unless you also view performing these exams as violating, and then you can thank me for mentioning them to you as your school might not have).

To make it clear, I had my scholarship withdrawn because I found performing these exams to be violating for myself. If you feel fine with performing these exams as long as patients are fully consented, then you can graduate from school and hopefully become a very much needed advocate for patients.

However, from what I experienced as a student, I can assure you that if you want to stick to your values regarding patient modesty and legal rights, you will have to "be different" than almost everyone around you in medical school. You would think students would be punished for abusing patients, but in reality they are punished for defending patients. If you want to truly preserve your morals about informed consent, you will have to enter school with the stubborn mindset that you will consistently question your superiors. For example, when a preceptor introduces you as a "doctor" only to increase the likelihood that a patient will allow you to do these exams on him, then you will need enough moxie to refuse on spot to go by that false entitlement and reveal in front of both the preceptor and patient that you are in fact only a "medical student", and then ask the patient more honestly if you practicing the exam on his body is still acceptable to him. Because even if this scenario does not seem as revolting as "gang raping" anesthetized patients, once you start shaving off bits of your integrity to avoid confronting problems inherent in medical schools today, then you will only continue to slowly chip away at it until you become what your preceptors are and what you were once horrified at the thought of becoming.

If you are considering medical school, I bet some readers of this blog feel relieved to know that you are preparing "for what is ahead" with an interest in preserving the human dignity of the patient population. As Jean stated: "Even though stressed student was only intending on going into research, I still wish she would have found a way to stay in the system because she would have made a valuable addition to the medical field with her viewpoint and committment to her morals/integrity."

And so I think many people would value your struggle to stick with your integrity in school, even if it is met with hostility. That is what I would have done: There is no way I would watch someone get violated without reporting it, whether it occurred in a hospital or back alley. Maybe you could initiate an organization that raises awareness among medical students early on that motivates them to fight for patient rights. Work with faculty to add it into the "formal curriculum". Attach a stigma to the medical student who is indifferent to the violation of patients. Anyway, whether it is because of increased empathy or just my own increased sensitivity to these intimate exams, it still disgusts me as much as it seems to for you, that doctors and nurses get away with sexually violating their own patients.

So I hope the article does not deter you from medical school, but makes you angry to change things. You can always email me (Dr. Bernstein listed the address), if you have not already without your pseudonym "Kristina".

"Yes she does go into greater detail about the medical abuses of women, but the reality is that women are far more likely to be coerced, intimidated or brainwashed into being victimized by these invasive procedures than men are. Sometimes it's almost like the medical profession treats being female as a disease."

Thank you Hexanchus, I could not state it better. American women get to be controlled and monitored at each major cycle of their sexual lives: Missed and painful periods, first time having sex, each pregnancy, each labor and delivery, menopause, and of course annual checkups between all of this nonsense for decades on end. In reality, their sexual organs are designed on the inside of their bodies to protect them from the hazards of the outside world, and so all this tinkering and squeezing and scrapping over the years introduces its own nosocomial harms. And who do women turn to when their sexual organs are damaged from "modern" medicine? Such as one too many colposcopies mousetrapping them into "high-risk" pregnancies? And then "high-risk" pregnancies mousetrapping them into complications like uterine prolapse later in life? Back to their own abusers each time. American women are living in an illusion of empowerment when they surrender themselves to be rescued from nothing by the Almighty Gynecology Gods.

I agree with your statement that the "medical profession treats being female as a disease." And as you read in my article, this patriarchal mindset was enriched at my school. When students learn to take sexual health histories, we are not told to ask boys and men the dates of their last testicular and prostate exams, but we are told to ask all girls and women the dates of their last pap smears. Who cares about women who are virgins, women who only have sex with women, and women who are in long-term monogamous relationships? Do not believe what women say about their sexualities because they will lie. Do not worry, women do not mind being exposed and invaded for no purpose. This all seems like very misogynistic and condescending lessons for medical students to be learning in this day and age. As you suggested, cervical cancer is a disease of lifestyle, not a disease of the virtue of being female!

"From an early age (ACOG is now recommending young women have their first GYN appointment at age 12-14) women are intimidated & coerced into getting their annual "well woman" exams."

I did not realize the ACOG actively recommended these "exams" at such young ages. So I researched and found your true statement in this article:

http://kidshealth.org/parent/growth/medical/first_gyn.html: "The idea of having a pelvic exam can make a girl feel nervous, embarrassed, or scared. By explaining why the visit is necessary, giving your daughter a sense of what to expect, and addressing any questions or fears she might have, you can help her feel more comfortable about taking this step."

This propaganda has an agenda to associate these "exams" with a glamorous right of passage for American girls "taking the step" into womanhood. They target impressionable females from young ages because they are easier to manipulate and intimidate into accepting "exams" when perfectly healthy, and because they can become lifelong customers, which increases the profit to be had from the cumulative damage done to their symptomless sexual organs.

Moreover, this propaganda restricts the legitimate reasons why some girls and women disapprove of pelvic exams to nothing but hollow "nervousness" and "embarrassment" and "fear", which is missing the whole human picture:

Many people have an innate urge to resist spreading and chaining their legs into stirrups for what has to pass as an "exam position". Most women only spread their legs for another person as a natural response when they desire to have sex, and so this "exam position" can be sexual for her while at the same time vulnerable because of the power gap between her and the fully-clothed provider. She can try to suppress all that is extraneous to her rational mind, and repeatedly remind herself it is only for a supposedly "neutral examination". But her body has its own intelligence, and when she is in that inferior position and her sexual organs are penetrated when she has no appetite for it, signals are transmitted to her brain, and a negative association is created between the sexual experience coupled with feelings of submissiveness and powerlessness.

That is why some women report feeling "violated" even when they have "competent exams" with "competent providers". For some women, the "wellness exam" itself can be sexual abuse and rape, especially when unnecessary and when alternatives exist. That is why I do not think this propaganda encompasses all reasons why some women reject their "wellness exams". In essence, the "wellness exam" can be worse for her health than the alleged chance of being rescued from disease, and the only one who can measure the difference is the individual herself, not distorted propaganda nor her brainwashed mother.

"It's a process that in most cases informed consent is conspicuously absent from. Want hormonal birth control? Put your feet in the stirrups & spread em! Never mind that the exam is not necessary or in any way related."

Thank you for mentioning this, Hexanchus. Unfortunately, the OBGYN "Associate Dean for Curriculum" at my school is one of these shameless health "care" providers who lies through his teeth to illegally coerce girls and women into these exams by blackmailing birth control prescription. Coercing people into sexual penetration without medical need is sexual abuse and rape.

What perplexed me the most was the way his mannerisms reversed so abruptly that he could not even discuss the topic without snarling at me, even though I brought the article not to dispute his practice but to defend myself and a minority of other students as belonging to a group of sane adults who oppose these exams without emergency need. How ironic that in my pursuit to defend myself and future students from lack of informed consent in medical school, he not only invalidated our feelings as students, but he also admitted his own unethical practice of disregarding consent for patients, and invalidated their feelings as patients as well.

As long as medical students are trained by corrupt instructors like this, many girls and women will continue to be cheated (and sexually abused and raped) into having pelvic exams without consent, even when they are still virgins needing birth control to have sex for the first time. With unscrupulous criminals like himself at the top of the totem poll, it will continue to pass as a sick rite of passage in this country.

"I'll accept that some of SS's writings might appear to be slanted toward the female perspective, but I believe there are valid reasons for that - not the least of which she is a young female and viewing it from that perspective. Additionally, when she objected, she was ultimately referred to the head of OBGYN, so her experience was contextual in that respect as well. In fairness though, she was just as abhorrent with regard to rectal exams performed on male standardized patients."

Thank you Hexanchus, for backing my message. I had no interest in commencing a war between the sexes.

My article defends not only male and female patients, but also male and female students.

What you said makes sense: I witnessed more abuse against female patients in medical school, and hence reported that more in my essay. I also scrutinized that abuse from my female perspective:

1) The only combination of abuse I witnessed in medical school was two male physicians abusing female patients (I did not witness female or male nurses or physicians abusing male patients, female nurses or physicians abusing female patients, or male nurses abusing female patients). First, I simply stated the fact that these two male physicians (the OBGYN Dean and head ECM instructor) disregarded female patient legal rights to ask for what they sought, which was same sex health care. After that, I included my own philosophies from a female perspective that this specific request (females asking for females to do their "exams") was not always "sexist" as these male instructors blindly "educate" students to view it as (arguing that some females have innate instincts and consistent life experiences to feel safer with females, as well as personal, cultural, and marital values to prefer females doing their "exams"). I then expanded what I witnessed to discuss the generic laws that allow all patients the legal right to request same or opposite sex intimate health care. I included these broad statements to defend both male and female patients, even though I never directly met or heard of faculty who deprived male patients from these basic rights.

2) I was sent to an OBGYN Dean who withholds BC from females, and not to a Dean who withholds condoms and Viagra from males. This Dean became cantankerous when I brought in an article about females getting unwanted pregnancies after avoiding pelvic exams for BC. I was tearful when I presented the article because I was defending myself from the school treated me like a "one time freak", when in fact you can see I am part of a larger group of people who take issue with these exams in non-emergency events. And this Dean does not even pretend to respect his patients, but thrives off his position to abuse them and their reproductive rights. It is not uncommon for girls and women to report feeling "violated" and "raped" from these "exams" especially when they realize they were fooled into them for nothing but money and power trips. Some frightened teenagers and adults are unable to know and stand up for their rights in these scenarios, and these patients trust that providers will hold their physical and emotional well being as priority.

Unfortunately, physicians like this Dean take advantage of these patients, using blackmail and intimidation to cause unnecessary humiliation via "exams" recommended by conflict of interest rather than genuine medical need, something that is clearly illegal as per the Patient Bill of Rights. I believe this person is a serial sexual offender (and so much worse I have to censure anything explicit here), and somehow he fools an apathetic school to bestow him the leadership of "educating" the next generation of gynecologists about how to "care" for girls and women. What is worse, this person admitted his sick practices so bluntly to me, because he is accustomed to students not questioning them. Frankly, I suspect other students secretly feel he is very wrong but how can they report something like this? That their Dean molests patients? Even for me to report it here as an ex-medical student who is not in the same country is distressing because it seems like outlawed conduct. Still much of my article reflected this account, and I received emails from (mostly female) readers who were disgusted but not surprised to read about the abusive OBGYN Dean at "my school". Even though the consequence was that my article disproportionately benefits female patients, I know it was the right thing for me to write about the situation at length.

3) "My school" trains students to give pap smears to females without need. I have never heard of a female saying she enjoyed these "exams", and the medical community knows this: Why else would they hang stupid posters on ceilings to distract females from the fact their private bits are being trespassed? Convincing patients to "consent" to having their sexual organs penetrated for no medical benefit, while at the same time knowing it causes them negative feelings, is sexual abuse and rape. How can this be promoted at "my school"? I wrote about this in my article too as it was another unacceptable aspect of medical training that bothered me, even though the effect was that my article advocated more exclusively for female patient rights.

Because of the three reasons outlined, my article might be more profitable for female patients. But that does not mean I do not think male patient rights are less important. It just means I witnessed abuse of female patients more in my one year of school.

"I find it interesting that we are willing to deny ss using the same arguments and feelings as we do as patients to plead our case. And we as patients denying to validate her feelings much the sam way the medical community ignores our contentions. I understand the situation is different in the fact that medical students do or should know what they willingfully enter into, something like a patient entering into a medical facility for a test. Do we not hear or see the same thing, we assumed you researched this and understood that we were going to."

Thank you Alan, that is exactly how I felt when I started reading about patient modesty violations as a medical student. I took up an interest very quickly because I saw many similarities between the ways lack of informed consent abuses both patients and medical students. It is unprofessional to tell gang-raped patients they "should have known" that students also practice pelvic and rectal exams, just as it is to tell young students they "should have known" about taboo and invasive genital exams on both sexes when many have not had neither and all have not had both exams in their own lives.

"The point is there are areas where ss could practice that would not require her experience in penetrating a vagina or anus. Just because the system isn't set up to do this does not mean they should not, just like providing for patient modesty. Just because they do not provide same gender unless asked (if then) doesn't mean they shouldn't."

Thank you Alan, I think until they have an official list of graduation competencies ("my school" had no such thing), then the system should not force this on all misinformed students. I agree with you that some students enter fields that do not require these experiences, and so forcing them on uninformed students does not necessarily make them better doctors, and even worse, it might make them resentful toward their education if it causes them enough stress to faint and cry and relive rape experiences.

"While I am a little dumfounded that one would enter medical school without suspecting this would be part of it, I still support her right to enter into a field and not do this if there is no real valid reason to do so other than...becasue we always did it that way."

I did not suspect these exams would be part of the curriculum because I did not know about them. I had never seen any descriptions or diagrams or images regarding providers sticking their lubricated fingers up vaginas and rectums at all let alone as part of routine physical examinations. I never learned about the intricacies of these exams in high school or college courses (or the first year of medical school we still never even discussed pelvic exams), and I never learned about these exams from friends or family. After conversing with students and faculty, I learned I was not the only student who did not understand these exams before school. I think it is merely a stereotype that incoming students have an extensive clinical knowledge base, as if they could already be physicians without schooling. In actuality, most of them only have an extensive scientific background as that is the total focus of prerequisite courses and medical school entrance exams.

Medical school definitely spews out the "Because We Always Did it That Way" gig. I was very assertive with my request "my school" screened future students. I spoke with several more Deans than the ones mentioned in the article and relayed to them what physical exam instructors revealed about students having difficulties. As far as I know, "my school" still does not screen students because they are just too content with the status quo. How hard is it for them to add explicit descriptions of these exams into the packet they already mail out to accepted students?

"My feeling is that if a school has a curriculum that students should know what's involved from the beginning and make their choices based on that. The platform needs to be open instead of secret and if someone chooses not to participate, it is their choice."

Thank you Belinda, I do not understand why an institution of higher education gets to pass being so lousy with its communication to students. Why can informed consent be shelved when it comes to students? It remains a violation nonetheless.

"The difference is that SS can walk and choose a different career but we are dealing with our very lives, our health, our mental health."

I was able to choose because I had a full scholarship and could thus leave debt-free. But students like the one who cried to do the prostate exam are swamped in thousands of dollars of debt, and so they do not have much of a choice. And this student could have suffered "mental health" problems to be forced to do the exam while pardoning her reaction because of previous sexual abuse. Obviously she related the two life experiences, and she might have even relived her traumatic experiences. That is why I do not support "my school" and its decision to continue overlooking the topic after such incidents.

"First of all, PT, there is no reason to be insulting to SS. She is a highly intelligent person who has put herself out on a limb by speaking out about modesty and the status quo. She has opened up dialog about heretofore taboo subjects. Secondly, I would like to hear some good solutions from you and the other angry men regarding these issues. Perhaps your angry rhetoric in this blog it is making you feel better but you are directing your anger at the wrong people."

Thank you Charlotte, I would not minimize how men feel about modesty in medicine. PT contributes valid points that are often discussed on the Blog. But honestly just because they do not coincide with the abuse I witnessed in medical school and hence reported here does not mean I do not sympathize with them, and certainly most posters including you seem concerned for both men and women, and so I also think he is directing his anger at the wrong people.

"The administrator acknowledged that many men were uncomfortable having to disrobe for radiation treatment in front of the female techs (I had male and female techs until I made a fuss). Why did none of them protest? Why was I the first person to have to go through the ordeal and stress of going up against the system? And, believe me, it was very stressful! They have made some major changes at this center because of my advocacy. I wish someone had spoken out before I was a patient there as the experience has left me scarred and damaged."

There are too many reasons to list why no one before you would protest even if it bothered them tremendously. And the longer people are silent about it, the more difficult it is to break that silence. I believe you when you say it was very stressful. But your advocacy did translate into changes for the better. And thank you for relating your story to my story in that we both put ourselves "out on a limb". I hope my advocacy is as productive as yours, mostly that it convinces "my school" (or even better the AAMC) to consent students, something I believe should have always been required.

"It made me wonder if other posters here have brought this up with their family and friends to see where they stand on things. Until we can "recruit" more people to this cause it still seems like we are a small group."

I spoke with family and friends about the topic, and I do not think we are such a "small group". My younger sister also thinks the exams are violating. When I first told her about these required exams for medical school, she thought I was joking and almost disconnected the phone. Several of my female friends (not in medical school) did not know about pelvic exams and made very negative comments when I described them. Also, I had two roommates when I was in medical school. One was in her early thirties, and she told me that despite having the exam for years, she still has issues with it and the first time she had to reschedule the appointment several times because it was icky. Moreover, I asked the school psychologist about how people react to the exam because my school treated me like I had some sort of "abnormal reaction", and she assured me she sees girls and women "all the time" in the clinic who do not want to submit to pelvic exams. Of course her solution to the problem is to "fix" these "disturbed" people so they can accept their annual "wellness exams".

I also asked several medical students about the topic, and they are no different than the general population, and perhaps even more modest when in the patient role themselves since they know all the more that "professionalism" is a superficial term that does not eradicate human emotions. One of my roommates was a female resident and she told me she makes it a point to only visit female gynecologists, although it may be because of her religion. Another friend came to medical school as an aspiring OBGYN; she is a little older and actually had a baby recently. She told me she seeks all-female OBGYN clinics because she "cannot help but think some of the men are perverts." I spoke with one other friend who asked to be my partner for the physical exam class. I told her then why I was leaving, and she suggested for me to just not show up for the workshop, and said she personally had no problem performing these exams on either gender. But when I asked her about her life as a patient, she replied "I would never let a man do that to me! I have no idea why a man would go into gynecology!"

In all, I spoke with about 25 women on the topic, and every single one said she either preferred or required female intimate health care.

I realize this is a small sample size (that does not include males) but most people I asked (whether medical students and residents or not) have modesty concerns, whether it is to avoid the exams altogether or avoid the exams if their preferences cannot be actualized. So I think the trick is what you said to "recruit" more women (and especially men since they tend to be silent) to be more vocal about their concerns that were always present for many of them.

"This brings me to another point where I agree with you PT that SS could have went on to complete her training, got her MD and then been a champion of patient rights. That would have been a better read."

I was not able to complete my training because I found parts of it violating. I still hope the article brought you insight from an inside view of how students are systematically desensitized to patient modesty.

"Students have largely been portrayed as beings who step foot onto a campus and somehow selfishly lose all rational consideration regarding anyone's modesty but their own. It seems that's not always true, because “SS” later speaks of the realization of patient modesty as well. Could she have ‘sucked it up” and later become a strong advocate for patients?"

Thank you swf. I agree students seem to have their own personal modesty. I think many students have empathy for patient modesty as well but steer clear from the issue because faculty attach a stigma to it.

At my school for instance, the head ECM instructor has a huge influence on first and second year students because his two-year course covers almost all preclinical preparation for patient interactions, since most of the other courses at the time focus on the basic sciences. Part of the stated goals of his class are to provide "an introduction to ethical and legal issues relevant to the care of patients" and "recognize and describe common reactions of patients to doctors" and "relate to patients in the context of the changing social, cultural, legal, political, economic, and personal contexts which affect the delivery of health care."

Well as I wrote in the article, my classmate told me this instructor reprimanded the request of a female to have a female provider do her pelvic exam. Of course her request is a legal one that can be derived from cultural, social, and personal contexts, and even though my classmate said he thought her concerns were "understandable" especially since both him and the male instructor were surrounding the patient, he was not able to question the instructor. I only attended the first year of the course, but I imagine from what my classmate told me that this instructor does not bother to incorporate anything regarding legal patient modesty rights in the second year either, even though students should be made aware of these legal issues.

I should tell you, I attended an elective seminar with a small number of students organized by this same instructor that covered gay and lesbian and other sexual minority patient advocacy. We had a transsexual patient talk to us about her hassles in the clinical context when she must ask for prostate exams instead of pap smears, much to the confusion of providers, since her internal organs remained unchanged after sex reassignment surgery. Of course it must be awkward for patients like her to have to correct providers, and she advised students to provide forms in clinics that allow patients to indicate these scenarios before meeting face to face with providers.

What I am saying is this instructor is a big advocate for reshaping clinics to allow patients to have their intimate medical needs met without derision and disbelief. But at the same time, he teaches students to scold a female who makes her legal request to have another female do her pelvic exam, even though this request could be deeply related to her own sexual identity and values and maybe even previous sexual abuse that needs to be tolerated by practitioners without shame and ridicule. Why then does he not advocate for but actually shun a similar cause? My guess is that advocating for transsexual patients seems "progressive" to him, while advocating for patients who strongly prefer either same or opposite sex health care seems "backwards" to him.

So students, such as my friend, learn from this youngish, LGBT-advocating instructor what is progressive and what is not.

As a side note, I think the patient who asked this instructor to leave the room during her pelvic exam might have been following her instincts about him. And if so, I think her instincts about him were spot on. After all, he is someone who arguably has mistreated and sexually abused his own students, including a crying one who admitted to already surviving sexual abuse, and not only did he do nothing for future students, but he also did not care in the least bit to meet with another student down the line (me) who voiced problems over the same exams in his class. And so I think the patient was correct: This instructor is consistently not someone who respects others and how they view these intimate exams, and she deserved "care" from a more open-minded and considerate individual anyway.

"Now, I am not referring to any other medical school except USC Keck but I can' imagine other schools would not describe for potential students what is expected."

Thank you Dr. Bernstein, I did not include details about this topic in my article as it was already lengthy. Obviously it is very relevant to my complaints.

I should say I spoke with several other faculty members than those mentioned in the article (who I chose to highlight because of their abuse of patients). The truth is, not a single faculty member could direct me to a source that ensured all incoming students knew about these exams. In fact, they did not make much of an attempt to do so because they have seen students like me before. They seemed to know and accept that of course a proportion of young students are not going to understand the mechanics of these exams, let alone the fact that they are expected to perform them first on actors and then on patients. So I am confident to say that at the time, incoming students were not directed to a resource that explained that component of the curriculum. And as I mentioned in an earlier comment, I did read the entire packet mailed to me as an accepted student, and initialized each item on the list about clinical expectations, that I then had to send back to the school along with an acceptance fee. These exams were entirely unmentioned.

Even worse, the same instructor who told me about the "one female in the male rectal exam" rule also told me that a student directly told her she "wished she had known about [prostate exams] earlier." It of course irked me to hear this, and I asked why nothing was done. The instructor told me she added a statement on the ECM course website, something about students needing to be able to perform "invasive exams". It was a vague statement like that, that obviously still did not qualify as full informed consent. And even then, I could not find her alleged addition to the ECM course website.

Dr. Sherman looked through websites from my school and stated on his Blog: "Now there may be more detailed outlines given to prospective students, but the online description does not per se mention intimate exams. So it is certainly feasible that a student who had no experience with these exams could be taken by surprise." (Thank you Dr. Sherman for looking into that).

In addition, I met with the Dean of Students during my first semester (before meeting with all these other instructors the following summer). And I did ask her how students would know about prostate exams, and she told me "They wouldn't, unless they shadowed a primary care physician." So this person was as aware as other instructors that my school does not provide students with that fair opportunity. The only reason I did not ask her the same about pelvic exams was because I still did not know about them myself at the time; there is no official discussion of them the entire first year of school in fact. And since my school has no official list of graduation requirements, she had no list to hand me at the time either.

To be honest, I think students from other schools are also not made clear about these exams. As I stated in a previous comment, my resident roommate told me she did not know about prostate exams when she started school, although she had no problems with them. And her resident boyfriend spoke very unfavorably about these exams, telling me he had no sexual appetite for one month after learning pelvic exams and was happy to never have to do them again. When I asked him about prostate exams, he became defensive and awkward and told me he "got out of learning them". After he left our apartment, my roommate laughed and said he obviously took issues over the same exams I did. My sister was also visiting me at the time, and she was also laughing, saying "You are so not the only person who has problems over these things!"

I could write about additional private conversations I had with people that convinced me some students do not know about these exams and then face issues. I think when I admitted my own problems, people were more honest about their own problems that they would otherwise not discuss. That is why it irritated me that schools looked past these embarrassing problems they observe each year, knowing that students cannot bring them up without looking immature and incompetent. That sort of stable oppressive system is something that has always bothered me. It does not matter since it is only a minority of silenced people who are really in trouble. Who cares about them?

Medical schools do not seem to take the issue seriously: At least at my school, when I urged them to screen future students, and even after publication of these articles, I never heard back from them about my request. So it is likely they did not and will not change. For these reasons, I have been in contact with the AAMC, with suggestions that they explain these requirements on their site that virtually all students use to apply to medical schools. It is 2011 after all. They should be sophisticated enough to value informed consent.

I of course will not judge your medical schools because I do not know whether they fully consent incoming students, and if not, then what action they take for the students like me who inevitably have issues.

But I will argue here what I think constitutes "full informed consent" regarding these exams:

1) Faculty must directly refer students to material that explains these exams. Preferably it is within a "Student Handbook" mailed to students who can then initialize that they have read the material and return it with their application fee. It cannot be one of many potential resources that students can download and peruse if they by chance stumble upon it after clicking on an arbitrary series of tangled links off their school website.

2) The resource should not simply state that "intimate exams will be covered". I did suspect this when applying to my school. Instead, there should be detailed and methodical explanation (and if needed diagrams) perhaps all combined onto a separate page of its own right about "Intimate Physical Exams for Male and Female Patients" that explicitly describes these exams such that no student is left misinformed. Because I was shocked to learn that completing an "intimate exam on a male patient" meant I had to lubricate my fingers and insert part of my body into his rectum, just as I was shocked to learn that completing an "intimate exam on a female patient" meant I had to lubricate my fingers and insert part of my body into her vagina and rectum. Descriptions like that are entirely absent but then forced on all students.

My point is that some young students from this generation do not understand how "intimate" these exams are considered to be in some medical schools in America to even worry enough to research the mechanics behind them in the first place. This is not a "chicken or the egg" dilemma of what comes first: People will not understand these exams until they are explained to them, and not the other way around. That is why "full informed consent is important". These exams warrant special mention because unlike other medical exams, they are sexual abuse and rape (more than anxiety and fear) for some students when not fully consented. Based off the reaction students routinely exhibit when preparing to practice these exams, a minority of them are likely to benefit from "full informed consent".

3) The resource must indicate to students that they are expected to perform these exams on both paid actors and real patients.

SS /hex. I am not sure I fully understand your position regarding the difference between the way genders are treated in the medical community. While I understand the position that females are brought into the system earlier and on a more regimented basis due to the gyn needs, I can tell you bending over and placing you elbows on a table is no less uncomfortable for a male and as Dr Sherman pointed out ignoring modesty issues begins very early for young males as they go through sports physicals in a manner that females do not. While it is true females may go through a gyn exam before males endure prostate exams, the crux of this issue is ignoring the feelings, concerns, and comfort of people, patients or students. And when it comes to that area males are far more likely to be discriminated against. Without rehashing old arguments male modesty without a doubt receives less consideration. Interesting side not a Dr Orange from USC caught alot of heat when she made flippant comments about male medial exams using phrases like stick our fingers up your butt, and feel your balls...and felt no issue with it when members of this forum called her on it.

SS, I have read your comments with interest. I worked in a pediatric teaching hospital for 15 years. During that time I heard physicians state that they should be turning away patients whose parents declined to allow their children to be part of research protocols. When parents did refuse the staff physicians and residents would on occasion become very nasty. Turning patients away was not permitted whether parents were bullied into consenting or not.

Two of the MD's I worked for did have a discussion one day on having to perform pelvic exams. One had never performed one, the other only once as an intern. This would have been almost 30 years ago. It made me wonder. Have you considered transferring to another medical school that might have different requirements to graduate?

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SS Show me a facility where male patients are treated this well! You can't and that paintsthe real picture in healthcare,not what you saw in the classroom.

To SS: My comment regarding "recruiting" more people to the patient modesty cause just means that I wish more individuals would voice their concerns when visiting doctors, etc. I do realize that a lot of people have these modesty concerns but I don't think most of them voice them when in the medical arena. That is why I don't think attitudes are going to change system-wide until enough complaints/concerns are received. That is what I meant about talking with friends and family to find out their feelings on this. Perhaps if they feel this way they can be educated on the fact that they can voice these concerns to their doctor. If more and more people are willing to talk about this maybe a systemic change would be more likely to occur. There are too many people that just accept the status quo and take what they get, then end up feeling "violated", disrespected and in many cases unwilling to seek care in the future.As far as the gyn exams (well woman exam, etc.), there are so many American women that believe these exams are necessary to their health that they just accept them as a necessary evil. But they have always been so disturbing to me that I refuse them. (From either a male or female doctor, although if I ever needed one for a specific problem I would definitely go to a woman.) I also have never understood the rationale behind doing these if I am already healthy and asymptomatic. And I do know other women who feel the same as I do, so we are out there.To me the biggest issue in all these discussions is that we are all different, with different feelings, morals, etc. and the medical world doesn't seem to address/recognize this. They conveniently assume that we all will accept whatever care is available and so do not ask patients if they have preferences. That is why I think more people should be convinced to voice these concerns with their doctors/providers. Jean

For those who won't copy and paste, I am sorry but I can't create a clickable link to PT's outside reference site because of a current Blogger.com system problem. My advice: try copying and pasting.. it takes only a couple seconds longer than clicking a link. ..Maurice.

Thanks Dr. Bernstein for correcting my spelling. Her comments were actually made on her blog called Daily Strength under the topic "The real reason men do not seek healhcare" or some such similar title. It was discussed I believe here but I do no believe she ever posted though I and several others invited her. It was a very telling conversation as I and several others challenged her that while we understood she was perhaps trying to be funny, this type of attitude toward men's health contributed to why men do not indeed seek medcial help as perhaps we should. When confronted with if a male MD made similar flipant comments about females and gyn exams they would be roasted. She was also challenged with the issue of female clinics and healhcare centers for women without the same for men. Instead of addressing the issue she launched another thread asking if there was a need for mens clinics, and started it with her opinion that no we did not need men's clinics as their needs could be met in the general medical community. "This despite she has a concentration on women's health and not sure but possibly worked at a women's clinic. It was amazing for several reasons, she never did acknowledge her comments might have been inappropriate regardless of intent, she saw no need for male clinics but focused on female health and supported women's clinics, and guess what, if I recall she was involved in teaching at med students at USC. The fact that someone could make these statements, be challenged on them, and not rethink at least the possiblity she was being a little one sided....and she is/was involved in teaching students how to behave and form their thinking? alan

I want to thank SS for continuing her contributions to the current and past ongoing discussions. I most appreciate her repeatedly taking on and referencing specific expressions by the various visitors and providing her interpretation of their meaning to her and significance. This dissection of an argument is as important in defining and clarifying an issue under discussion as a careful tissue dissection by the pathologist or surgeon or even a careful complete history taking and physical examination by the internist or family med doctor can lead to a diagnosis.

I know others here have done the same but in view of the plethora of responses by SS, I picked her today to say thanks.

I do hope that all that has been discussed here will "go somewhere" and "make something worthy happen". ..Maurice.

Dr. Orrange is listed as an assistant professor in geriatric and internal medicine.Charlotte SS I think one of the reasons men have remained silent is for many years men who expressed issues with female providers were labeled as sexist. this double standard still exists in society today. take the example of female reporters in the locker room where if male atheletes complain they are labeled as the problem, thses things make it hard for males to step forward and file complaints when they assume they will be attacked for shining a light on it. this would not likely happen to females as they are more likelynto recieve a sympathetic response. now i do feel some get a little to focused on the double standard rather than solutions, but it is a valid point and it has some part in tis discussion. to ignore it, downplay, or say it is irrelevant once again pushes it to the back where it has been till now. i do nit agree with PT's approach but I junderstand his frustration with male modesty being met with scorn as often as concern....alan

Nursing schools/programs outnumbermedical schools by hundreds to one. Countless derogratory sexist comments have been made about menin these often women only classes. Such as assaulting male patientswho had an erection,using a steel spoon. Specific instructions weregiven to nursing students by theirnursing instructors in carrying outthese tasks.

PT:While I understand (and sympathize within) what you say in theory, blaming "SS" because we want more men to do what she did just does not make sense. What you are doing rather, is discouraging anyone whether male or female from placing ethics over career goals and the bravery to speak about it. Certainly we would all love to see a male version of this scenario put such effort and blind faith into disclosing feelings that actually offend and dissuade them from a career path, but we can only ask Doctors' Bernstein and Sherman if there are any such people willing to share with us at such great length. Until/if/when we see such a creature, is it not better to applaud such efforts than to tirade them into having no meaning?Can we not all see the good within her discourse? Are steps toward considering patient modesty just as valid coming from either gender? If she speaks from a woman’s point of view…so what. She is still a brave woman. If she reports to us that she saw more abuse in one area than another…so what. She reported what she saw. These are all steps we can take as PATIENTS and not just women and men.Why are we unwilling to just take help and support from where we get it? If it angers anyone that she is a woman speaking out, then implore more men to be brave enough to come here and do the same. In the meantime, it is not her fault that men are not doing the same, but it is to her credit that she did.

First, I will mention again that I do not believe ssexists let alone her story and certainly that is myprerogative. She seems transfixed on pelvic examsand her comments about this subject continues toad nauseam. Additionally, I see a close resemblance to the womenagainst stirrups postings and can't help but wonder therelationship. It really isn't about women against stirrupsbut rather women who don't want men performing pelvicexams. My comments are and have been, then don't see a malephysician.Women have always had these choices as wellas an abundance of female physicians and female nursepractitioners to choose from. Men have the same choices as well regarding the gender of the physician. The problem for men is the overwhelmingfemale support staff. Women truly have no real privacyconcerns to speak of and essentially, I see their complaintsmore as a smokescreen to simply explain away the vastInequalities,discrimination directed at men.

PT, as far as I am aware, SS does exist and not as just some pseudo-person or ghost but a writer representing herself. Joel and I have been involved with her dilemma for over the past year. I think you should relieve yourself of the cynicism regarding her existence and deal only with the discussion points that she presents. I am also sure that she would admit that the pelvic exam issue both with what she confronted as a med student and her understanding of what is confronting all women at times is frankly nauseating, if not worse, to her.

I agree women are potentially "better off" than men in the acquisition of a healthcare provider of their gender than a man but, unfortunately, that's how it is until the are changes the system. ..Maurice.

I believe my cynicism iswell directed. SS is not a patient,admits she has never been to agynecologist. The topic of thisblog is patient modesty and therefore how can she ever empathize or relate to anyone of us! She is just an observer,a participant if you will and nevertruly experienced what many of ushave.

PT, the primary theme of SS here and to me and Joel personally in the past year has been one of dismay and anger about the way she was treated as a medical student by those officials in the medical school regarding her request to avoid having to perform invasive rectal and genital procedures, which teaching sessions were grossly unacceptable to her. She subsequently extended her discussion to what she considered other excesses in medical school education such as pelvic exams on women without their consent.

I found that the scope of the issues she presented was consistent with a general topic of modesty issues which is the topic of these threads. Remember, this 6 year thread was begun on the general issue of patient modesty with no direction by me to focus on only male or only female patient issues. Yes, there has been a persistent drift to the male issues but that was created by the visitors and not me. I really don't intend to change the title of the Volumes to "Male Patient Modesty" though I hope this view of patient modesty is continued if there is continued value to its discussion. ..Maurice.

I agree with Dr. Bernstein. I appreciate SS's contributions to this blog. Although she has a perspective from the "other side", it is a valuable one in that it may help to understand the viewpoint of medical personnel and work to make changes to that. After all, I think the contributors to this blog not only want to voice their complaints but also want to come up with solutions to improve medical modesty for both male and female patients. Also, what happened to Doug? Haven't heard from him in quite some time. He is a sane voice and generally has astute observations and contributions. Jean

Jean: I'm here and following the discussion. I'm working on another article for the blog I have with Joel Sherman. My new article will appear in a few days. It covers an interesting part of medical history that gives some insight into attitudes toward privacy and modesty and how these ethics moved from Europe to the U.S. Otherwise, I also appreciate SS's contributions. What she's giving us is an inside, under the radar look, at what goes on with the medical culture. Her experience reminds me of a quote I heard about warfare. In summary, the quote says -- The most sensitive and vulnerable soldiers are the ones least likely to survive the horrors of war. The cowards and selfish have a better chance of survival. This is not saying that only the cowards survive -- but that the cowardly and selfish have a better chance of survival. I think there may be an analogy with medical education. In some training cultures, the most sensitive and caring have those qualities beaten out of them and they become hardened -- either that, or they don't survive. In some medical schools, the culture is set up to see that only the strongest survive -- and this doesn't mean the strongest ethically or those that care the most, or those with the most empathy. It results in the survival of the egotistical, and cowardly and self-centered rather than the most sensitive and vulnerable. I can see a survival of the fittest attitude when it comes to learning the information and techniques. But not when it comes to the more humane side of medicine. Doug

"I think there may be an analogy with medical education. In some training cultures, the most sensitive and caring have those qualities beaten out of them and they become hardened -- either that, or they don't survive. In some medical schools, the culture is set up to see that only the strongest survive -- and this doesn't mean the strongest ethically or those that care the most, or those with the most empathy. It results in the survival of the egotistical, and cowardly and self-centered rather than the most sensitive and vulnerable. I can see a survival of the fittest attitude when it comes to learning the information and techniques. But not when it comes to the more humane side of medicine."

Doug, I don't think one can analogize between soldiers repeatedly facing death and medical students in their training. Yes, there are a number of "bad apples" completing medical school and the further training and yes they could and should have been detected and removed while they were students and that is a continuing failure in medical education but in no way is there any intent in devising medical school education program as a means to turn out unhumanistic, but strong "warriers". I can tell you after over 25 year after year experience with teaching first and second year students that our goal is to repeated teach and monitor for humanistic behavior and to attend to personal concerns and issues of every student. As I said, sometimes it turns out we fail (documented in the literature regarding correlation between negative student behavior in med school and the negative professional behavior years later when then reviewed.)

PT, write to Dr.Joel Sherman about your suggestion.. but I think he doubts they will respond (for academic privacy reasons) and so do I. Actually, that's why I didn't want to publish the name of the school or name names. ..Maurice.

Dr. Bernstein:In order for us to get a realistic 'take-away' from the students' post, and/or any possible inroads we may have in catching an opportunity of influence along a future caregiver’s path, I would ask:Have your students already come far enough within the system to either assume that their gender will not be an issue or perhaps simply SHOULD not be an issue?I realize that you have reassured us that you speak to them of respect of a patient in general terms, but have said that those lessons are not really related to the gender of doctor v. patient and the obstacles that type of modesty may create. Can we assume that by the time they reach your door that students have already received a great deal of influence/conditioning by others along the way and perhaps gender-sensitivity has already (for lack of a better term) been removed? It does seem odd that ethics and modesty would not include gender, so we would have to assume that others have already given students the (perhaps skewed) mindset of how to perceive patient gender concerns. In that scenario, I would have to wonder when a student is in their most open-minded state of such issues.If students are ‘raised’ in such an unrealistic and entitled environment, then they are certainly ill prepared to face the ethical/modesty/moral issues of the real patient.

PT, I don't have any statistic available but I would say you are correct about the very small drop-out rate of students in medical school. Most know very well what is going to happen to their lives before they apply and with the burden of work, permanent loss of time for private life and the huge financial burden for each year in school, there is very little incentive to permanently quit school after an investment of one or two years.

Now, in response to Anonymous of 12:45pm today:

Students entering medical school come in with whatever views regarding physican vs patient gender issues they have developed over the previous years but I have found no gender insensitivity with the first and second year students that I have worked with. You can see, as I have described previous, their personal gender sensitivity in whether or not they are inclined to allow a student of the opposite sex examine them. Modesty issues when dealing with real patients are also addressed and as I may have already written each system checkpoint list {description of how to perform a physical for a certain bodily system. such as the lungs or abdomen, etc.} starts out with the following: "Appropriately drape an attend to patient modesty during PE. Demonstrate concern for patient comfort." Note that "attend" and "demonstrate" does not imply simply "acting" but actually doing. The students are quite aware of the patient's potential modesty concerns but what my groups have NOT been aware until I was relaying what I learned on this thread is that a patient not spontaneously expressing verbally a modesty concern does not mean that the patient has accepted what is about to occur or what has already occurred. I hope I have answered the questions posed by Anonymous. ..Maurice.

Although this blog is over a month old, there were 165 comments posted in five days in response to a "extremely shy and modest female" who refused to have a male she had known in high school remove her catheter after surgery. (scroll to the bottom for the comments)She is called "crazy," "nuts," "neurotic," a "freak show loser," and "upright to the Nth degree." Most think she needs professional help to "get over herself."Worst comment from a poster : "Don't expect hospitals and medical personnel to move heaven and earth to ensure your highness that only those who you deem worthy will glimpse the holy temple that apparently is your body. Grow up!"

"but in no way is there any intent in devising medical school education program as a means to turn out unhumanistic, but strong "warriers"."

Maurice -- Of course, your correct. I'm not talking about "intent." I'm talking about the atmosphere, the ambience, the general world view that may exist in "some" medical schools. It's what exists under the radar, despite what the idealistic intentions may strive for. All institutions, I think, sometimes forget their idealistic missions when trying to deal with the day to day, minute to minute challenges. Same with medical schools. I'm certainly not suggesting that this is a program to create unhumanistic graduates. I'm not claiming my analogy is perfect, but I'm saying that sometimes the system beats down it's best by promoting not the ideal, but what's most efficient in the best interest of the institution. Perhaps it wasn't the best analogy. Doug

Doug, and, of course, I am looking at medical school practices from the viewpoint of my long term but limited first and second year exposure to the these practices based on what I see, what we are told to teach and supervise and on talking to my fellow faculty. Of course, what happens in later years and beyond has been out of my vision. I have never seen signs of unhumanistic approaches in what or how to teach or in the observed or reported behavior of the teachers. We take what we do as serious business since we know that in these first two years we must set the standards so that later when the students get exposed to the inevitable "hidden curriculum" they will have the mind to "fight back". Anyway, that is our hope. ..Maurice.

I've just posted a new article on the blog Dr. Sherman and I run about patient modesty and privacy. My article is called ‘It’s no trifle to be a medical student in Paris’American Medical Students in France." It's an exploration into one theory as to how the history of attitudes toward modesty developed in Western medicine. I'm particularly interested in hearing from Dr. Bernstein as to how he views this point of view. You'll find the article athttp://patientprivacyreview.blogspot.com/ Doug

"Excellent presentation! I am sure we could do more to educate the medical student to look at the patient as a human individual with pycho-social issues complicating the biologic and which represents much more than "that gallbladder in Room 202" or that "flat plate of the abdomen". We try but much is defeated later in the student's careers by the limitations of time and the need to attend to "making a diagnosis and setting a treatment plan" and then, guess what.. moving on to the next patient. I think we have moved a whole lot away from the limited medical knowledge and the practice philosophy of that earlier era in France but our current medical system needs further changes to assure truly humanistic treatment to every patient regardless of social status or gender. ..Maurice.

I would like to comment on the post about the young lady who wrote in to Annie's mailbox about a male nurse she knew in high school being assigned to remove her catheter. The responses to that letter were mostly that she was "nuts" and that she should not have a problem with the sex of health care providers. It was the same old argument of they are "professionals", they have seen it all before, they are just doing their job, etc. Again, it is seem from the provider's viewpoint and not the patient's, even though this if from other potential/past patients. Granted, the young lady did seem to have a problem with her boyfriend but her request for all female gare givers for intimate procedures should be respected.It seems to me that people think that if their viewpoint is in the majority, everyone else should change to "fit in". This same issue was brought up by stressed student about her medical school. She said they accused her of being "immature, possibly sexually abused,etc." because of her viewpoint and that she should change to assimilate to the prevailing attitude, which she found unacceptable.Personally, I find it rather mean-spirited that others cannot accept and find validity in other's feeling, viewpoints, morals, etc. After all, at one time the mojority attitudes about such issues as slavery, segregation, women's right to vote, homosexuals in the military, etc. were quite different than they are now. It just seems to me that many of those who don't want to accept other's viewpoints are always so hostile: they just want everyone to be like them. Does anyone see my point? Jean

I finally found the closest match to a student handbook at the medical school SS attended and it covers what a student applying to the medical school could expect including, if accepted, but in rather general descriptions. It is not presented as a book itself but a series of website pages.

For example, pertinent to the concerns of SS:"students receive clinical training as part of their M1 training though the Essentials of Clinical Medicine (ECM) course, and particularly the Longitudinal Primary Care (LPC) program, a component of ECM. LPC pairs pre-clinical students with practicing physicians in a one-on-one mentoring/instructional relationship. Through this mentoring relationship and exposure to patients, students are introduced to a number of important concepts such as

While a number of these competencies will need to be mastered in the first year, all of these concepts and skills begin laying the foundation necessary for meeting the established competencies required for medical school graduation. Because the relationship between the patient and the doctor is central to all of clinical medicine, all medical students, regardless of their ultimate chosen specialty, will become better physicians by developing a solid foundation of these concepts and competencies"

Continuing with the description of what an entering med student should expect..

"THE CLINICAL YEARS: AN OVERVIEW

Our curriculum is designed to enable students to develop the basic competencies required of medical school graduates prepared to begin residency training in any clinical discipline.

Through participation in six core disciplines of medical practice and exposure to basic skills of medical/surgical specialties, students will practice the skills, attitudes, and behaviors unique to each discipline and common to the practice of medicine in general.

As their skills become more refined, students take on increased clinical responsibility as sub-interns and have the opportunity to explore particular fields of interest in a variety of settings through elective clerkships.

At the conclusion of their training, students will

have a clinical knowledge base appropriate for first year residentbe well prepared to provide care to patients in both ambulatory and hospital settingsbe skilled in the knowledge acquisition tools required for lifelong learnindeal professionally with the ethical, legal, and economic realities of 21st century medicine."

A description regarding Required Experiences relative to the concerns of SS was the following:

"Obstetrics/GynecologyThe objective of Obstetrics and Gynecology is that students acquire and apply the basic information and master the basic skills needed by all physicians who provide care for women, including the specific psychomotor and interpersonal skills necessary for the clinical examination of women. OB/Gyne is an ambulatory-based rotation. Students will see patients in a hospital setting during labor and delivery and the surgical aspects of the rotation."

There you have it. Not as specifically informative regarding what SS wanted to know in advance. Compare that to my USC Keck School of Medicine description to the public:

"I. PHYSICAL REQUIREMENTSAfter reasonable training and experience, the candidate must be able to observe and participate in demonstrations and experiments in the basic sciences, including but not limited to dissection of cadavers, examination of gross specimens in gross anatomy, pathology laboratory and neuroanatomy laboratories, preparation of microbiologic cultures, and microscopic studies of microorganisms and tissues in normal and pathologic states (e.g., streak plates, perform gram stains and use a microscope) necessary for such studies. Observation of gross and microscopic structures necessitates the functional use of the senses of vision and touch and is enhanced by the functional sense of smell.After reasonable training and experience, the candidate must be capable of performing a complete physical examination, including observation, palpation and percussion and auscultation. The candidate must be capable of using instruments, such as, but not limited to, a stethoscope, an ophthalmoscope, an otoscope, and a sphygmomanometer. The candidate must be capable of performing clinical procedures such as, but not limited to, the following: pelvic examination, digital rectal examination, drawing blood from veins and arteries and giving intravenous injections, basic cardiopulmonary life support, spinal puncture, and simple obstetrical procedures. The candidate must be capable of performing basic laboratory tests, using a calculator and a computer, reading an EKG, and interpreting common imaging tests. The applicant must be able to move in the clinical setting so as to act quickly in emergencies. At the conclusion of the Introduction to Clinical Medicine course the student will demonstrate proficiency in the skills described above. By the conclusion of the clinical clerkships the student should achieve full competence in the skills described above including the ability to synthesize and organize these skills."

Unless, there was more specific information presented to SS in the form of a contract to be signed, what I have presented is all that I could find. ..Maurice.

I was listening to NPR on the way to work this morning and heard a piece about treating waste water (toilet water) and using it for drinking water. The processes involved were so good, claimed the engineers, that the water was clean enough to drink. The problem was that the public wanted nothing to do with drinking recycled toilet water. The frustrated engineers complained that the public was irrational, they won’t listen, they don’t understand. Science showed there was no difference between the recycled water and fresh water.

So to help understand the public perception of recycled water, psychologists were brought in. The term psychological contagion refers to the habit we all have of thinking that once something has had contact with another thing, their parts are in some way joined. In other words, once something has been deemed “icky” then it is forever “icky”.

So how does this relate to patient modesty? We associate our reproductive organs with privacy, intimacy and sexuality. Are these organs to be associated that way under ALL conditions and ALL times, never to have that association broken, even temporarily when going to a doctor? Many people here say YES, those parts of the body are always private and intimate. The medical profession says NO, when there are conditions or diseases that affect those organs and the body they are attached to, they need to be treated and cured. There are no “special body parts”, all body parts are just “parts”

Lee, you bring up a logical point regarding the mindset of use of waste water and the mindset how we look at our own body parts. But, believe it or not, despite all that has been written here about how doctors consider patient physical modesty, there is some spot in the mind of doctors that there are modesty sensitive areas of the patient's body just as there are such areas in the doctor's own body. And we teach the students cautions about their behavior and actions when dealing with a woman's breast and male or female genitalia. So, yes, as physicians we consider the patient does have "special body parts" both healthy and when diseased. But also "yes" we are perplexed regarding the patient's goal if the modesty of these parts affects and interferes with proper diagnosis and treatment when diseased. ..Maurice.

Lee -- Interesting analogy. You write: "The frustrated engineers complained that the public was irrational, they won’t listen, they don’t understand. Science showed there was no difference between the recycled water and fresh water." Here's what I want to know -- Do these engineers use this "icky" water in their homes. Is that what they and their families and their children drink? You write: "So to help understand the public perception of recycled water, psychologists were brought in." How about the psychologists? Do their families, their children drink this especially treated water? I'm not demeaning your point. It's a good point. But so often the experts are "called in." What does that mean? Essentially means, they're not really "in" the formula nor do they consider themselves on the "inside." They're "objective. " They're on the "outside" looking "in" -- in most cases. Applying your analogy to patient modesty -- When all doctors and all nurses and all techs and all cna's and all medical professionals accept gender neutrality as their personal truth for their personal selves and for their closest family members -- then the same philosophy should apply to all patients. As long as medical professionals differ in this respect, have different values and preferences, so should that be accepted among patients. When all the engineers and psychologists drink the "icky" water as a standard, and serve it to their children -- then they can claim at least some ethical high ground and call those who don't irrational and stupid. Doug

"SS /hex. I am not sure I fully understand your position regarding the difference between the way genders are treated in the medical community."

I cannot speak for Hexanchus, but I believe males and females are mistreated in different ways in medicine. That is not to say there is no overlap in these trends or that one sex has it "worse" than the other. The problem lies at the individual level that someone feels mistreated, and their sex is insignificant. But as this Blog aims to improve medical modesty problems, it might be important to target how different patient populations, such as males versus females, are currently mistreated so that the areas can be better understood and addressed.

I think females are more often victimized into "invasive" (penetrative) exams without full consent: When alternatives are not offered, when they are not told the exams are unnecessary and harmful, and when the exams are forced against their wills (Hence I agreed with Hexanchus). In contrast, I think males are more often victimized into having their BFOQ interests shunned by the medical community and virtually unachievable within the confines of hospitals at large given the demographics of technicians and nurses (Hence I agreed with PT).

I am not saying these are the only modesty problems patients face. And I am not saying there is no overlap (Indeed two instructors at my school teach students to scold female patients who make BFOQ requests). However, since you asked for clarification of my "position regarding the difference between the way genders are treated in the medical community", I did and still do agree with statements made by Hexanchus and PT.

"Yes she does go into greater detail about the medical abuses of women, but the reality is that women are far more likely to be coerced, intimidated or brainwashed into being victimized by these invasive procedures than men are."

I agreed with Hexanchus' statement here that females are more often "victimized" by vaginorectal exams ("invasive" genital exams) than males are "victimized" by rectal exams ("invasive" genital exams).

Even the leaders at my school mislead females into accepting unrelated pelvic exams for BC, and recommend pap smears to females with zero risks, such as virgins. Some American females lose their virginity to cold chunks of metal or lubricated gloved fingers because they are duped into being tested for STDs or because they are seeking BC to have sex for the first time.

I think cheating young females and even virgins into pap smears is a disturbing American phenomenon. It means lucrative business, and the high false positive rate especially in younger females means many of them undergo unfair personal crises when told they "might die from cancer" and crawl back for nastier biopsy violations (that in turn might cause problems later in pregnancy), hence the "victimization" of these female patients in terms of "invasive" (penetrative) exams. The one-sided and in-your-face propaganda and brainwashed mothers in addition to the young age of female patients means many of them cannot do their own research to defend themselves because they are too inundated with fear-mongering coming from all directions.

I cannot think of an analogy where virgin males are duped into STD testing that requires penetration of their sexual organs for the first time, warned pathology results indicate they might die from deadly STDs, frightened into biopsies from young ages where providers situate their faces between their spread-eagle legs staring into their crotches while scrapping bits off their sexual organs even though it could never save them from deadly STDs because they were (although some would argue no longer are) virgins in the first place.

The medical community has a stereotype that since females are more often the ones who accept penetration in sex outside of medicine that none of them mind being penetrated in sexual organs for medicine either. I say this first because the OBGYN Dean at my school believes his patients, by virtue of being females, will accept his fingers in their vaginas or else they cannot have basic reproductive rights. I cannot imagine a "respected leader" at a large medical school teaching students that male patients must accept fingers in their asymptomatic rectums in order to have sex in this country.

I also say this because for years men have been given the option of PSA, while females decades younger are not informed about CSA blood alternatives. Whenever humiliation and unwanted sexual penetration can be sparred for patients, it should be. Why does this country believe such consideration only applies to males, and not to females?

Even if some providers do not trust PSA or CSA blood tests and only use them as adjuncts, screening for cervical cancer has more humane alternatives routinely hidden from American females (such as vaginal swabs and self-pap tests). When a female has a traditional pap smear, the provider scraps her body to send to a pathology lab. This is something that she could do herself in the privacy and dignity of her own home. There are self-pap kits designed by biomedical engineers where a female can easily insert a device that clicks into place at her cervix, rotate it the number of times indicated in the instructions, and send it to a reputable pathology lab. I think the most disturbing part of the traditional pap smear is the submissive interaction with the provider, and obviously self-pap tests eradicate that unfair power differential. Moreover, some females experience physical pain during traditional pap smears because their bodies naturally clench up at the thought of being penetrated by strangers when they have no desire for it. And so some of them might have more control over that problem in their own homes as well. Gynecologists never seem to think about all these important and natural aspects of female physiology and psychology to at least offer these alternatives to patients who might choose them over the traditional pap smear. Instead and to their advantage, they mitigate it all to "immature fears".

I do not think females are as clueless about their bodies as the founders of modern gynecology portrayed them. Females know how to insert tampons from young ages, and learn how to wipe in the correct direction to prevent rectal bacteria from entering their vaginas from young ages. They do not consult medical providers each time or even the first time they insert a tampon or wipe themselves. Why then do medical professionals condescendingly believe all females cannot follow simple instruction sets about maintaining other aspects of their reproductive health such as self-pap tests? My guess is that these "care" providers do not "care" about how all females feel about these exams, they only "care" that females waste their time, dignity, and money setting up annual appointments while being deprived of alternatives that could liberate them from it all. By the way, this is in contrast to traditional prostate exams, where providers arguably have a purpose to do the exam since they need tactile information to determine the status of the gland. I do not know of any creative alternatives for men at home. So do you see my point? Unlike prostate exam screening, safe and effective alternatives do exist for cervical cancer screening outside of blood tests but are being withheld and discouraged from patients!

I also want to point out that the lithotomy position for females requires both visual and tactile invasions, as opposed to the prostate exam position for males only requiring tactile invasions. The lithotomy position has the practitioner seated between the spread legs of the patient from a young age, starring at her intimates and penetrating them with both fingers and instruments and lasting in that position for longer durations than the prostate exam. I am not minimizing how some men feel about prostate exams because it all depends on individual values and experiences. And as I stated, I also refused to perform prostate exams and so I look down on these exams as much. I too would not want to bend over at a table and have the exam done. I am only rationalizing some of the differences between the positions male versus female patients routinely endure in medicine for their routine "invasive" exams.

What is worse, though, is that the lithotomy position itself invites practitioners to violate females in so many ways that are less likely to happen to older males during prostate exams. Some females only want or need part of the exam completed. But they often receive the full exam that includes speculum screening and bimanual exams even though the later is declared by countless reliable medical associations to be utterly useless. And even worse, some females (including teenagers and virgins) have rectal exams performed on them without prior explanation. I blame it both on the stereotype that females do not mind being penetrated and on the lithotomy position itself since it permits the practitioner too much control over female bodies. Some practitioners quickly sneak in the rectal exam without permission since they are between her naked legs when she is lying down vulnerably that way anyway. This all means that some healthy females receive what is considered the most invasive aspect of genital exams for healthy males (rectal exams) decades before males do, sometimes without consent, and even when with consent, they still have the exam performed in a position where the practitioner not only has a finger up their rectum but also has his or her face right there creepily watching the process, like it is the front row of some peeping theater, the whole time.

Not to forget that the lithotomy position itself invites additional violations for a pregnant female, by which time in her life she has already been accustomed to being penetrated without true consent anyway. My Aunt and one friend from medical school both had their water broken without consent. And laboring women have unnecessary pelvic exams without consent. Again because the lithotomy position renders them defenseless to repetitive violations. Add to that the fact that scientists for decades have warned that the lithotomy position is physiologically dangerous to the patient (decreasing pelvic opening) and her baby (decreasing oxygen supply), and so this beloved position can also be blamed for excusing additional "invasive violations" like episiotomies.

The fact that more women are entering gynecology is not improving these old establishments fast enough. Most of them have already accepted these violations in their own lives since young ages, and they are only adopting the patriarchal belief system laid out by the founders of modern gynecology. In some ways, the problems are masked now that as many women as men violate female patients. This is repeated history: Whenever an oppressed group starts to realize they can fight their oppressors, some of their own members fill the shoes of the oppressors, which masks the true motivations and origins of the problem and delays its fix. Not much different than brainwashed Chinese mothers who wobbled in misery their whole lives only to turn around and bind their own daughters' feet for their own "good", when it was only for the "good" of the male minds who started the foot-binding fetish.

Women entering gynecology today think they are doing such "good" for other women, but many do not realize how much better the field could and should be.

I do not know if Hexanchus's statement and my agreeing with it offended you, but do you understand why I quoted and agreed with it? I do not mean to say males are never "violated" by "invasive exams", or that it would be less important at the individual level if they were to be, only that it does happen more often to female patients of all ages and that part of that is due to the corrupt minds who created the field and still hold the most powerful positions today (OBGYN Deans of schools).

When it comes to "non-invasive" (non-penetrative) genital exams, I would say young males are just as often mistreated. I thought some of the revelations on these Blogs about boys feeling ashamed having female nurses do their sports physicals was sickening, and I would never invalidate their feelings if they did prefer a male provider or no exam at all.

And I whole-heartedly agree double standards surround these dynamics: A female examining a male patient who wants male care is decent, but a male examining a female patient who wants female care is indecent. They are equally indecent because the practitioner ignored the feelings and legal rights of the patient, which can leave some feeling violated.

I think these double standards are also what authorized Dr. Sharon Orrange to write in her manner about male patients, where in the reverse scenario that a male physician would speak so rudely and unprofessionally about female patients ("You are afraid we will stick our finger up your vagina and squeeze your boobs. We will"), it would have made news. As you suggested, these double standards nudged their way into medicine through osmosis of social norms at large.

Dr. Orrange frequently responds to comments to make good use of patient feedback. But after Dr. Sherman called her out and his readers challenged her dismissive attitudes toward male modesty, she did not even respond to any of the intelligent and well-meant comments. If what you say is true, that she posted a new topic after that with her opinion that males do not need or deserve men's clinics the way women have benefited from women's clinics (at least in terms of BFOQ laws), then I believe she destructed the purpose of her own Blog to interact with and amplify silenced viewpoints (such as male patients fighting for modesty rights). I think her second post seems passive-aggressive: After entirely ignoring a deluge of comments about male modesty, she firmly stamped her opinion onto a new post to make it clear that these voices meant nothing to her.

I would not be surprised if what you say is true that she also teaches medical students. We can only hope her students follow her Blog and agreed behind her back (or even better to her face) with what some of the commenters said about male modesty. I do not think she should be dealing intimately with patients, and teaching students how to do so. I might think differently had she at least responded to comments even if her intentions were only to be humorous. But she did not, and that is weak.

And to reiterate, I did agree with PT several times and other posters that males are much less likely to benefit from BFOQ laws. As I stated to him: "I agree with you PT that medical BFOQ issues for men are pushed to the back burner [...] According to men on these Blogs, all-male men's health clinics would also be appreciated, and so obviously their BFOQ interests have not been actualized by the medical community the way they have been for women." I do not mean to say females never have their choice of provider sex withheld from them, or that it would be less important at the individual level if they were to be, only that it does happen more often to male patients because of these double standards and the way hospital employees are constructed at large.

I think male and female patients are both mistreated (even if in different ways) when it comes to modesty in medicine. And I think abuse against both sexes concerns most readers, even if they are only directly hurt by that of their own sex, most have friends and family members of the opposite sex. So hopefully these Blogs continue to gain momentum in the direction of all-inclusive advocation, like you said "the crux of this issue is ignoring the feelings, concerns, and comfort of people, patients or students".

"Two of the MD's I worked for did have a discussion one day on having to perform pelvic exams. One had never performed one, the other only once as an intern. This would have been almost 30 years ago. It made me wonder. Have you considered transferring to another medical school that might have different requirements to graduate?"

Thank you for your comment, J. It made my day (even if it sounds pathetic) to hear from an adult who knows (and seems to respect) physicians who have not performed these exams. I am curious, do you think your coworkers attended schools that did not require these exams, or asked for alternative assignments in school as I did when they discovered these exams?

I think it is true some schools do not require these exams. My school did not have an official graduation list that specified these exams, and neither does the LCME which accredits medical schools in this country.

To be honest, what bothered me the most was not that I did not graduate, but that I endured so much abuse I should not have experienced had I known to not matriculate at "my school" in the first place. I was plucked out of my classmates as the "clueless moron" and "immature one" who is "totally incompetent". And so I left school not only wasting time and money, but also salvaging my self-esteem from all the negativity said or implied about me ("oblivious", "juvenile", "squeamish", "too weak to accept a challenge"). I can say with confidence these exams are not "queasy little challenges". I find them unethical to be forced on non-consented students with troubles when unnecessary, especially on actors.

Then when I discovered "my school" expects a few students like me to suffer each year, it made me feel all the more disrespected. You would think in 2011, higher education institutions with their anti-discriminatory claims would not bully students, who hold different beliefs about sensitive areas, out of their system when they fail to screen them out ahead of time each year. Instead that is not the case, and I hope it has meaning for me to raise awareness on public forums like this one about abusive schools like mine that still will not consent incoming students. I want to ensure future students are not put in compromised positions, and that is why I have been in contact with the AAMC since they screen all students applying to all medical schools. I am very serious when I say I believe pressuring students without prior consent might be sexual abuse and rape for a small minority of the thousands across the nation.

"But they have always been so disturbing to me that I refuse them. (From either a male or female doctor, although if I ever needed one for a specific problem I would definitely go to a woman.)"

You and I have the same plan here!

"They conveniently assume that we all will accept whatever care is available and so do not ask patients if they have preferences. That is why I think more people should be convinced to voice these concerns with their doctors/providers."

I agree any patient should feel confident to voice modesty concerns with providers. And as you said, the problem is too many providers make convenient assumptions, and some patients might not have enough confidence to confront them. I think the best improvement might then need to come from both directions (from "inside" the system with training medical and nursing students to not make assumptions, and from "outside" the system with helping patients feel more confident to voice their concerns).

I mean how many teenage girls feel confident to confront some god-like doctor who lies to them they need pelvic exams for BC? And how many teenage boys feel confident to tell to the face of a female provider already rushing into an intimate exam that they prefer a male provider? And what about patients who do not speak English? Or patients who are shy about questioning authoritative figures? In some cases, the situation is too intimidating for patients to make requests. Even if a patient silently accepting the conditions might pass as "consent" by lawyers (since the patient was not screaming "NO!"), it does not pass as "consent" by humanitarians (since the patient felt threatened to voice important concerns).

Although it would not solve all problems, I think it is feasible to retrain providers to always ask patients if they prefer male or female care in intimate settings before prepping for an exam. At least that would remove one stumbling block for patients who would otherwise need to ask to the face of providers already preparing for the exam to leave the room if they are not of the sex they prefer. As I stated in the article, students across the country are taught to never assume all patients are heterosexual when taking sexual histories. And to think that not too long ago, patients admitting gay lifestyles might have been referred for psychiatric help. Why can't the same progress be made about the unfair assumptions providers make about all patients not caring whether the person doing their intimate exams is male or female?

Thank you for the link. I feel sorry the poster had to endure so much ridicule and hostility.

It is neither practical nor productive to invalidate that some people find these exams sexual when they involve manipulation and penetration of sexual organs between sexual human beings. Although the exams are clinical, that does not mean they cannot be defined multitudinously: Autopsies can be both morbid and clinical, hip replacements can be both violent and clinical, knee-jerk exams can be both goofy and clinical, and intimate exams can be both sexual and clinical.

For that reason, I do not think it is fair for "Dear Annie" to tell this patient she cannot call it a "violation". Although the nurse finally did grant her request, he did not do so without resistance. He questioned her thinking, and hence "violated" her right to make legal requests without barriers. What if she was too ashamed to continue to fight for her rights when this "professional" challenged them? He obviously would have done the procedure and that would have been a "violation" because instead of honoring her original and true requests, he would have resorted to intimidation and ridicule to silence them.

You can feel the hostility in some of the comments, and I cannot help but think it is because some of the commenters are intimidated with what she has to say. Maybe deep down they feel the same way she does about these exams but cannot admit to it because they are in denial as a means to cope with accepting similar fashions in their own lives. Why else would the personal story of a woman who felt violated about what happened to her in the clinic make them so furious to call her "psychotic"? Maybe then they are also the "crazy" ones.

Your link reminds me of a medical student version of all this posted on a forum for students here:

A medical student starts the forum by stating he or she desires to avoid performing rectal exams especially on standardized patients.

There are several straightforward comments from other students ("I don't think it's that dumb a question" and "It seems to vary a lot between schools.")

Some responders reveal admission of problems ("I can't help but think that the people who sign up to be standardized patients for rectal exams are getting off on it.")

On the second page of comments, there are lots of jokes. Inevitably some students express ridicule and contempt for the poster.

Worst comment: "we doctors are a different breed that the lay public can't even begin to fathom. congrats on your discovery, may your newfound knowledge make you the most homosexual and freaky of us all!.....seriously, grow up."

"It's called institutional mindset. They are, after all, the "experts", and anyone that disagrees with or challenges them must have some kind of problem."

It seems to be an "institutional mindset" across many schools.

The NYT article "Teaching Doctors Sensitivity On the Most Sensitive of Exams" features someone named Dr. Mark H. Swartz, who apparently directs pelvic exam training for six medical schools. He states that the "reluctance of doctors to perform routine pelvic examinations needs to be addressed." But then we see that his method for addressing such doctors is to call them "very immature" and from "sheltered social backgrounds". I think this person is himself from a "sheltered social background" the fact that he somehow organizes this training for hundreds of students each year without preparing for and respecting students who have survived rape or who are from other cultures where these exams are seen in different light or who simply view these sensitive exams differently than himself. I think he should swallow his own insults he felt so confident to publish in a large newspaper, and maybe talk to his students who have concerns, realize their concerns are not always "immature" ones, and hopefully next time think twice before publicly demeaning his own troubled students he knows little about. When I read this article as a medical student preparing to leave school, I was on the verge of tears for days afterward, because he reminded me of my own faculty. Now when I look back at the title of the article, I have to wonder which doctors should be taught sensitivity on sensitive exams - The students, or the doctors themselves who claim to be teaching sensitivity to students?

SS while i agree with some of your points I stll disagree. i have been to two urologist and my pc and all three have insisted the psa is in addition to the dre, my company uses drivers with cdls, the male drivers have to have a dre, the females do not, we provide health and life insurance, males dre required no pelvic for women. for many men it is a drop your shorts and bend over the table, i assure your for a man this is just as unnatural and uncomfortable as stirups for women. yes women start with these exams earlier in life, but I would lay money there is much more concern about draping and all of the other "considerations" for female patients than for men. If you look back over the passion and the sheer length of your post it is easy to see you feel very passionate about this, I would suggest its normal for one to see the things they experience personally and identify with more intensely. I would not expect a you to fully understand my experiences as a male anymore than i can of those of yours as a female. i think this bears out through this whole issue, providers do not feel as passionatley for patients modesty untl they are the patient...alan

"i have been to two urologist and my pc and all three have insisted the psa is in addition to the dre"

I am aware some doctors recommend blood tests only as adjuncts. My point was that the availability of PSA, and not CSA, does minimize the overall incident of male patients receiving invasive genital exams. My other point was that invasive prostate cancer screening needs tactile information (which a patient cannot effectively complete himself), whereas invasive cervical cancer screening needs microscopic examination of cells (which a patient can effectively prepare herself).

"for many men it is a drop your shorts and bend over the table, i assure your for a man this is just as unnatural and uncomfortable as stirups for women."

I agree these positions can be as traumatizing for any man as they can be for any woman. But I pointed out the lithotomy position does invite additional violations of females of all ages, whether teenagers submitting to pap smears but then also suffering bimanual and rectal exams without permission, or laboring women suffering exams without consent.

I wrote at length to defend the specific statement from Hexanchus that women are more likely to be "violated" by "invasive (penetrative) exams" physically forced on them when in powerless states (lithotomy positions) or when true consent is unlikely (laboring women, women desperate for birth control, and impressionable teenagers).

This is of course only a sliver of patient modesty problems. I believe any asymptomatic male or female should have the opportunity to accept risks and waive exams. Males should be allowed to play sports without unnecessary hernia checks. Females should be allowed to access birth control or deliver babies without unnecessary pelvic exams.

And I believe your company is no better. Men should be allowed to work there without facing employment or insurance threats. Although one could argue these men could simply find another job, I have to wonder whether that is possible for all of them. Some might have already been working at the company when the requirement was introduced. And some might not be informed about this policy until they have already committed time and energy. In those cases, when salary and status is blackmailed, I would definitely agree this is a situation where men, as opposed to women, are "violated" by forced "invasive exams" which is just plain unacceptable.

Does your company tell men this before they are hired? Or does it wait until they have worked an entire year to tell them to bend over for their paychecks? Because such a situation would remind me of my medical school waiting until uninformed students have dished out thousands of dollars to then force compliance. If I were a man working at your company, I would do the same thing I did in medical school. Did you ever refuse? And what do you think happens to men who do? Also is your company located outside of America?

I do not want to give the impression that I believe it is more or less problematic for males versus females to be mistreated in medicine. The truth is that both males and females should have complete control whether or not to undergo exams while asymptomatic, and should have their BFOQ preferences actualized should they accept exams.

What I find discouraging is the lack of progress to change the system. Why haven't more males questioned genital exams for sports? Why haven't more female virgins questioned invasive STD testing? Why haven't more females questioned pelvic exams for birth control? Why was the term "birth rape" only coined recently when it plagued females for decades? And why haven't more men at your company questioned required rectal exams? These are all examples of authoritative figures controlling individuals and their genitals. And in each case, there has not been enough voice and/or enough reaction to voice to effect change.

We saw the reaction when commenters kindly and respectfully questioned Dr. Sharon Orrange and her stance on male modesty. She shamelessly and publicly ignored all comments as if they came from a gaggle of foolish children during their elementary school recess break. I think it is particularly saddening because these people who are raising awareness for male modesty expect so much ridicule over the silent topic that they have little choice but to do so anonymously on the Internet. And she is both a physician and educator of physicians who encourages anonymous feedback from patients on her Blog. It was an opportune chance for her to embrace the comments and have positive influence on her students and patients, but instead she snubbed the whole topic.

I can tell you as someone who tried to advocate for future medical students and their rights to have full consent regarding these exams, my efforts were shunned just the same. Perhaps I can publicize what the AAMC stated to me about my concerns, which was of similar derision with what I received from my own school. And perhaps I can also tell readers of this Blog how my school responded to my article. For now, I will say it is obvious to me my requests to improve conditions for futures students is not likely to be considered.

SS, do you have any information regarding how your views expressed here (specifically with regard to invasive rectal/genital examinations) match those of other countries or other cultures for example, in oriental or in Muslim cultures.

By the way, you can describe the response you got from your school to your article but with continuing anonymity of the school, as you have, on this blog. ..Maurice.

The Doctors TV show is obviously going to do a segment in the future titled "Are you afraid to go to the doctor?" One of the questions they pose is "Has it been years since you've seen a doctor?" You can go to their website under "Be on the show" and submit your story. I thought maybe some of the people here might consider doing that, especially if the modesty issue has kept them from going to the doctor. It's not exactly a fear but is definitely a reason some of us may not have seen a doctor in years. Maybe if enough people express this modesty issue as a reason, they would consider giving it some air time. I doubt it but nothing ventured, nothing gained. Of course, someone would have to be willing to go on national tv to talk about this, which may be a deterrent for some. Maybe they will see that people's hesitance to see a doctor is for more than the corny fear of needles assumption. I went on and submitted an entry myself. I really don't expect to get a response, though, but there may be some power in numbers. Jean

SS, At long last someone that shows an ounce of sanity regarding this most difficult topic!That said, some medical schools should not be let off the hook, and deserve to be made responsible for this despicable problem.I live in the developing world, and there is no such thing as private medical school, evertging is standrdized and regulated by the State. The problem is that pelvic & breast exams and prostate checks are compulsory, and provided by usually nineteen or twenty year-old med students, and they almost aways do them on extremely oor patients. If the "patient" doesn't submit, he gets no medical services at all, no matter how young, old or sick he/she is, or whether he's consulting for a comletely unrelated reason. As for the student, if he doesn't do them, she/he'll never graduate, either. Blackmail on both sides, but all too often, some faculty members and students are exploitative. They know discerning people don't want to be used as teaching meat, so they prey on the poor and those on need. I apologize for writing somewhat disrespectfully, however, I once let medical students become involved in my care and now regret it, mainly for the blatant disregard of my rights. Wait, what rights are we talking about? when we become patients we've none, don't cha now? And students don't either. The stupid and unchallenged assumption that such rarely performed tasks, (and ones that yield so low clinical value at that) are essential requirements to be a god physicians should be strongly discarded.

Maria, can you tell us when you use the expression "developing world" did you mean specifically a "developing country" and, if so, within which one do you live and have had the experience you describe for your medical care? ..Maurice.

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